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WHO Library Cataloguing-in-Publication Data

Advocacy, communication and social mobilization (ACSM) for tuberculosis control : a handbook for country programmes.

1. Tuberculosis - prevention and control.

2. Behavior therapy.
3. Patient advocacy.
4. Consumer participation.
5. National health programs.

I. World Health Organization.

II. Stop TB Partnership.

ISBN 978 92 4 159618 3 (NLM classification: WF 200)

© World Health Organization 2007

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 Table of contents
SECTION 1 -- PREPARING TO TAKE ACTION
02 Introduction
04 Chapter 1: Understanding advocacy, communication and social mobilization
06 Chapter 2: Developing a TB strategy incorporating ACSM
09 Chapter 3: Maximizing skills through partnerships

SECTION 2 – CORE DEVELOPMENT PROCESS

14 Chapter 4: Conducting a situation/needs assessment
20 Chapter 5: Designing ACSM interventions
22 Chapter 6: Developing ACSM messages and concepts
25 Chapter 7: Developing ACSM materials

About this Handbook

SECTION 3 – IMPLEMENTATION AND EVALUATION
This Handbook is a guide to support the design and implementation of effective advocacy, communication and
social mobilization activities in tuberculosis (TB) control at country level. As declared by the Stop TB Partnership’s
31 Chapter 8: Implementing ACSM activities
Advocacy, Communication and Social Mobilization Country-Level Sub Group in its “10-Year Framework for Action,” 35 Chapter 9: Monitoring and evaluating ACSM activities
a significant scale up of advocacy, communication and social mobilization (ACSM) is needed to achieve the global 43 Chapter 10: Documenting results and providing feedback
targets for tuberculosis control as detailed in the Global Plan to Stop TB 2006–2015.

Increased efforts and attention to TB are particularly essential with the growing emergence of multi-drug resistant
(MDR) and extensively drug-resistant (XDR) tuberculosis. ACSM activities can support timely diagnosis and treatment 47 REFERENCES
completion, which will minimize the chances that resistant bacteria will evolve.

This handbook is primarily intended for staff that plan, organize and supervise TB control activities at the national ANNEXES
level. Because tackling TB requires commitment and work at all levels, this guide can also be used by TB control 48 Annex A: Selected strategic assessment and planning tools
staff at the provincial, state, and regional levels; by nongovernmental organizations (NGOs) and others involved in TB
control, including communications officers, epidemiologists, program supervisors, TB medical specialists, nurses, 54 Annex B: Assessment of advocacy, communication and social mobilization in national
bacteriologists, statisticians, health educators, logistics officers and trainers. tuberculosis programmes
56 Annex C: Examples of ACSM goals/indicators
Health managers of refugee and displaced population camps, prisons and large private enterprises, such as factories
and mines, will also find this handbook useful. Additionally, teachers in medical, nursing, laboratory and public health 58 Annex D: Planning a World TB Day event
schools may find valuable information for training their students in effective, multi-disciplinary TB control. 61 Annex E: The stages-of-change model
64 Annex F: Worksheet for a creative/strategic brief
This handbook was prepared for the Stop TB Partnership by the Academy for Educational Development (AED) and
the Program for Alternative Health Technologies (PATH). The Stop TB Partnership is grateful for all the staff at AED 66 Annex G: Sample recruitment document for a focus-group discussion
and PATH and members of the ACSM at Country Level Sub Group who provided valuable input in the development 70 Annex H: Sample guide for a focus-group discussion
of this publication. 75 Annex I: Sample questions for pre-testing materials
77 Annex J: Sample questions for evaluating an advocacy initiative
December 2007 78 Annex K: The Patients’ Charter for Tuberculosis Care

SECTION 1
Preparing to take action
Introduction
By the end of this introduction, the reader will understand:
1) what advocacy, communication and social mobilization
(ACSM) is;
2) why it is essential to the Stop TB Strategy; and
3) how it can be used to identify and address TB control
challenges.
1. What is ACSM?
The three terms – advocacy, communication and social
mobilization – have been defined in many ways and are the
subject of continued debate in the fields of public health
and communication. For the purposes of this handbook,
however, the definitions below apply.
Advocacy
At the country level, advocacy seeks to ensure that national
governments remain strongly committed to implementing
TB control policies. Advocacy often focuses on influencing
policy-makers, funders and international decision-making
bodies through a variety of channels – conferences,
summits and symposia, celebrity spokespeople, meetings
between various levels of government and civil society
organizations, news coverage, official memoranda of
understanding (MOUs), parliamentary debates and
other political events, partnership meetings, patients’
organizations, press conferences, private physicians, radio
and television talk shows, service providers.
The different types of advocacy are described below.
• Policy advocacy informs senior politicians and
administrators how an issue will affect the country, and
outlines actions to take to improve laws and policies.
• Programme advocacy targets opinion leaders at the
community level on the need for local action.
• Media advocacy validates the relevance of a subject,
puts issues on the public agenda, and encourages
the media to cover TB-related topics regularly and in a
responsible manner so as to raise awareness of possible
solutions and problems.
Communication
Behaviour-change communication aims to change
knowledge, attitudes and practices among various groups
of people. It frequently informs the public of the services
that exist for diagnosis and treatment and relays a series
of messages about the disease – such as “seek treatment
if you have a cough for more than two weeks”, “TB hurts
your lungs” or “TB is curable”.
Effective behaviour-change communication and messages
need to convey more than just the medical facts as, on
their own, these facts do not necessarily motivate people
to a visit a TB clinic or complete their treatment. The
messages should explore the reasons why people do or
do not take action on the information they receive, then
focus on changing the actual behaviour by addressing the
causes identified – social norms or personal attitudes for
example.
Behaviour-change communication creates an environment
through which affected communities can discuss, debate,
organize and communicate their own perspectives on
TB. It aims to change behaviour – such as persuading
people with symptoms to seek treatment – and to foster
social change, supporting processes in the community or
elsewhere to spark debate that may shift social mores and/
or eliminate barriers to new behaviour.
Social mobilization
Social mobilization brings together community members and
other stakeholders to strengthen community participation
for sustainability and self reliance. Social mobilization
generates dialogue, negotiation and consensus among
a range of players that includes decision-makers, the
media, NGOs, opinion leaders, policy-makers, the private
sector, professional associations, TB-patient networks
and religious groups.
At the heart of social mobilization is the need to involve
people who are either living with active TB or have suffered
from it at some time in the past. Empowering TB patients and
ACSM for Tuberculosis Control: A Handbook for Country Programmes
the affected community helps to achieve timely diagnosis
and treatment completion, especially among families of TB
patients. The Patients’ Charter for Tuberculosis Care (see
Annex K) outlines the rights and responsibilities of people
with TB. Initiated and developed by patients from around
the world, The Patients’ Charter makes the relationship
between patients and health-care providers a mutually
beneficial one. Implementing the concepts of the Charter
at all levels is an important social mobilization component
for better TB control.
Strengthening TB programmes in a sustainable way
requires involvement at many levels – individual,
community, policy and legislative. A single effort has less
impact than collective effort. Mobilizing resources, building
partnerships, networking and community participation are
all key strategies for social mobilization. Specific activities
include group and community meetings, partnership
sessions, school activities, traditional media, music, song
and dance, road shows, community drama, soap operas,
puppet show, karaoke songs and contests. Other activities
unique to a particular country or region may provide even
better opportunities to engage and motivate individuals.
Although distinct from one another, advocacy,
communication and social mobilization (ACSM) are most
effective when used together. ACSM activities should
therefore be developed in parallel and not separately.
2. Why is ACSM essential to the Stop TB
strategy?
The Stop TB global strategy, launched by the Stop TB
Partnership in January 2006, has six major goals.
1) To pursue high-quality expansion and enhancement of
directly observed treatment (DOTS) – short course.
2) To address the co-occurrence of TB and HIV,
multidrug-resistant TB (MDR-TB) and other challenges.
3) To contribute to strengthening of health systems.
4) To engage all caregivers.
5) To empower people with TB and their communities.
6) To enable and promote research.
ACSM activities can be used to achieve all six goals.
Incorporating ACSM activities as an integral part of
reaching objectives set by national TB programmes (NTPs)
is an effective approach to TB control. Over the years,
ACSM has been used successfully to address four key
challenges:
• improving case detection and treatment adherence;
• combating stigma and discrimination;
• empowering people affected by TB;
• mobilizing political commitment and resources for TB.
03
SECTION 1: Preparing to take action
Examples of these success stories are provided throughout
this handbook.
3. How to identify TB control challenges that
can be addressed through ACSM
Tuberculosis control presents many challenges, such as:
• delayed detection and treatment;
• lack of access to TB treatment;
• difficulty in completing treatment;
• lack of knowledge and information about TB that can
lead to stigma, discrimination and delayed diagnosis
and/or treatment;
• stigma and discrimination that can prevent people from
seeking care and diagnosis;
• misunderstandings and myths surrounding TB, including
the belief that it is “untreatable”;
• weak political support for TB programmes;
• insufficient funding for TB programmes.
Despite increased attention and funding in recent years,
these challenges have been difficult to overcome. ACSM
strategies however contribute to addressing many of them
successfully.
Inadequate funding and lack of political will has slowed both
the development of appropriate TB control policies and their
successful implementation at the central, district and local
levels. Even when good TB policies exist, there is often
a gap between the policies and the programmes being
implemented. Experience suggests that TB control services
are negatively affected if there is no strong commitment
from particular sectors of society, such as decision-makers,
influential political and community leaders. TB programme
planners therefore need to acknowledge the challenges
related to insufficient political commitment and to consider
how ACSM strategies can improve political will.
If people affected by TB can be involved in designing,
planning and implementing control strategies, their concerns
and the daily difficulties they face will be better reflected. As
noted in the 10-year framework, “there is an urgent need
for processes that will facilitate and empower communities
most affected by TB to participate in, take ownership of
and drive the agenda for the elimination of TB”. Community
empowerment has been shown to be effective in HIV/AIDS
programmes and in implementing DOTS programmes.
Public stigma is often the reason people with TB do not
seek diagnosis or care. Improved public education and
awareness-raising initiatives about what causes TB, how
it is transmitted and whether it can be cured can help to
mitigate the stigma, not only among health-care workers
but also among the general public.
 04 ACSM for Tuberculosis Control: A Handbook for Country Programmes
SECTION 1: Preparing to take action
Chapter 1:
Understanding advocacy,
communication and social
mobilization
By the end of Chapter 1, the reader will know:
1) how ACSM activities have been used to improve
tuberculosis control; and
2) how an integrated approach, incorporating ACSM, is
most effective.
1. How ACSM activities have been used to
improve TB control
Decades of experience with a wide spectrum of public
health programmes, including promotion of new behaviour
and new medical products (such as contraceptives, drugs
and vaccines), have shown repeatedly that ACSM creates
positive behaviour change, influences decision-makers,
and engages and empowers communities to change.
NTPs need to develop ACSM strategies according to the
specific epidemiological, socioeconomic and other realities
of countries.
The following examples demonstrate how ACSM strategies
have the potential to improve case detection and treatment
adherence, reduce stigma and discrimination, empower
people with TB and mobilize political commitment.
In both Peru and Viet Nam advocacy fostered political
commitment and involvement at all levels and kept TB in
the national spotlight. Mass media educated the public
and motivated people to use services and complete their
treatment. In both countries, all the personnel involved in
the TB programme were given training in interpersonal
communication and counselling to improve the relationship
between provider and client and ensure completion of
treatment. As a result, both countries noted that the rate
of treatment abandonment decreased as the programmes
progressed. Community mobilization activities educated the
public and reduced stigma associated with TB while also
creating a supportive environment for case detection and
treatment. Over time, both countries met the WHO targets
for TB control. This involved a long-term commitment: each
country took almost a decade to reach the global targets.
In Colombia, a mass-media campaign resulted in an
increase of 64% in the number of direct smears processed
by the laboratories and an increase of 52% in the number
of new cases of positive pulmonary TB, as compared to
the pre-campaign level. This demonstrates the key role of
communication in improving TB control. In Viet Nam, the
NTP ensured that all messages about TB – regardless of
whether they were through interpersonal communication
or community-based media such as local theatre – were
consistent. Evaluations of the programme revealed that
80% of the people responding to a nationally representative
survey knew that TB was a communicable disease, could
list basic TB symptoms, knew TB was curable, and
understood that they should go to a government health
centre for treatment rather than trying to treat symptoms
on their own.
Experiences in India demonstrate the value of community
involvement and mobilization in linking DOTS clinics with
private health providers and volunteers to diagnose early
and complete treatment.
In Nigeria, after discovering that some health-care
workers preferred not to be posted to TB clinics, periodic
“enlightenment” seminars and workshops on TB and TB
treatment procedures were held for medical personnel.
Anti-stigma training and education helped to ensure
that health workers (both providers of TB services and
administrative staff) received accurate information on TB
and developed greater sensitivity to the needs of people
with TB. Nigeria also held community-based rallies and
church services to dispel rumours and reach people with
messages about TB.
Experiences in Mexico and Peru strongly demonstrate
that using social mobilization to fight TB can bring about
changes that influence social development in other
ways. Intensive activities were sustained over time in
both countries. These included advocacy, mass media,
local media, counselling and community mobilization.
Peru collaborated with community surveillance units and
mothers’ groups to create links between health facilities
and the community and to develop materials that would
appeal to people with TB. Mexico designated “champions”
in most states to lead and participate in activities to keep
TB programmes visible and to engage communities.
Notably, political will to improve TB control was strong in
both Mexico and Peru – a factor that increases the chance
of ACSM activities being successful.
Viet Nam reached out to community-based organizations
such as associations of elders, farmers associations,
women’s unions and youth unions to organize activities and
serve as peer educators. Ethiopia tapped into “TB clubs”
to provide peer support that was shown to eventually boost
treatment compliance.
ACSM for Tuberculosis Control: A Handbook for Country Programmes 05
SECTION 1: Preparing to take action
In the Western Cape of South Africa limited health-care
access was viewed as a significant obstacle to reducing
TB cases. Farm workers in the Boland Winelands district
sponsored a community member to attend lay health-care
worker training. Armed with new-found skills and primary
health-care knowledge, the lay health-care workers
conducted monthly weighing and TB screenings, referred
people with TB symptoms to the local clinic, administered
DOTS treatment, supported families affected by TB,
treated minor ailments, and educated the community to
give them an understanding of basic health issues. This
social mobilization effort has led to a significant increase in
“...ACSM creates
compliance with treatment.
positive behaviour
Health workers stimulate people to talk to each other about
TB issues. TB action committees involving employers,
change, influences
employees, farm lay workers and community resources
such as schools, churches, social workers, NGOs,
decision-makers,
health representatives and the agricultural private sector
have been formed. These committees address lifestyle
and engages
challenges faced by the farming community by organizing
and developing capacity-building events, recreational and
and empowers
health promotion activities for women, men and youth.
communities to
In Brazil, government officials in the states of Rio de Janeiro
and São Paulo helped to establish nongovernmental
change. ”
organizations (NGOs) and to get existing HIV/AIDS NGOs
engaged with TB. This included the São Paulo State
Forum of AIDS NGOs that supports 180 community-based
organizations in fighting HIV/AIDS. Groups in both states
have initiated efforts to engage and educate the broader
public to give them an understanding of TB and the
relationship between HIV and TB.
2. Why an integrated ACSM approach is
most effective
The experiences described above show the need for an
integrated approach – incorporating ACSM – to maximize
impact. As shown in Viet Nam and Peru specifically,
integrating communication activities into all TB control
programme activities not only led to meeting global targets
for TB control, but also helped combat various obstacles
along the way, such as political and environmental
challenges and long-standing stigma among health-care
workers and the general public.
 06 ACSM for Tuberculosis Control: A Handbook for Country Programmes
SECTION 1: Preparing to take action
Chapter 2:
Developing a TB strategy
incorporating ACSM
By the end of Chapter 2, the reader will have learnt how to
assess strategic ACSM needs for a TB programme.
To develop an effective TB strategy that incorporates ACSM
activities begin by obtaining accurate information on the
country’s TB problem. Much of this can be done through a
very basic situation analysis – ideally by the NTP or another
national authority that has the technical cooperation of
WHO, NGOs, other international organizations and people
affected by TB. A needs assessment tool has been
developed by the Stop TB Partnership to assist in country-
level planning. Though not specifically intended to assess
ACSM needs, this tool provides an idea of what a needs
assessments would involve. Chapter 4 addresses needs
assessments specifically for ACSM.
The situation analysis should gather basic information
on different TB issues in each region of the country. The
information required includes:
What obstacles prevent implementation of interventions or preventive actions?
Why do these obstacles exist?
How can these obstacles be removed?
What opportunities exist for addressing these obstacles?
Who “controls” these opportunities?
What must be done to “capture” these opportunities?
• demographics and socioeconomic status;
• epidemiology of TB in the country;
• the political environment;
• other TB control activities in the country (focus on what
is effective and what is not working – such as why some
activities are successful and why they work, as well as why
other activities do not work as well as anticipated).
Once this type of information has been collected, NTP
managers and technical staff can determine the programme
goals and the most significant constraints to TB control,
then consider how ACSM activities can help.
The analysis might reveal a wide range of challenges that
should be addressed, such as:
• the DOTS strategy not being implemented;
• the TB programme not being a high political priority;
• an increasing prevalence in MDR-TB;
• an increase in the prevalence of HIV/AIDS that is directly
affecting TB morbidity and transmission of TB infection.
The questions in the table below focus on how to overcome
these challenges and assess the issues. Space is provided
to answer the questions.
ACSM for Tuberculosis Control: A Handbook for Country Programmes 07
SECTION 1: Preparing to take action
Five tools that help with strategic assessment are described
below. Annex A contains more information on each.
• The P process: Created by Johns Hopkins University,
the P process lays out a logical framework for a
communication intervention – analysis, strategic design,
development and testing, implementation and monitoring,
evaluation and re-planning. The process has been applied
to a wide range of health issues.
The communication-for-behavioural-impact
(COMBI) approach: Developed by the WHO Social
Mobilization and Training Team, this approach aims to
mobilize social and personal influences to prompt behaviour
change and maintenance at individual and family levels.
• Johns Hopkins University’s outcome map to
“To develop an
strengthen the DOTS strategy: This planning tool matches
communication responses to programme needs and
effective TB strategy
outlines key planning and measurement indicators. The
outcome map retrofits communication interventions onto
that incorporates
the well-established but medically-oriented DOTS strategy
for TB control. It enhances DOTS to include demand
ACSM activities
generation for high quality DOTS services and suggests
strategies to encourage adherence and treatment
begin by obtaining
completion.
accurate information
• The communication for social change approach
advocated by the Communication for Social Change
on the country’s TB
Consortium: Through public and private dialogue people
define who they are, what they need and how to get what
problem.”
they need to improve their own lives. This approach uses
dialogue that leads to collective problem identification,
decision-making and community-based implementation
of solutions. It is communication that supports decision-
making by those who are most affected by the decisions
being made. This is especially appropriate for strategies
where social mores – such as stigma – act as a barrier to
behaviour change.
• The “cough-to-cure” pathway is another tool that
can be used to guide the strategic planning process.
Developed by the Academy for Educational Development
(AED), the pathway helps TB control programmes identify
where drop-outs are occurring. It identifies six steps to ideal
behaviour in TB control and the most common barriers at
the individual, group and system levels. It is based on the
idea that understanding the behaviour of people living with
TB is fundamental to designing interventions to strengthen
NTPs, including communication interventions. More details
on the pathway are provided in Chapter 4 and Annex A.
Ultimately, decisions on which strategies and approaches
are most appropriate need to be taken at country level
within the context of the NTP.
 08 ACSM for Tuberculosis Control: A Handbook for Country Programmes
SECTION 1: Preparing to take action
Using epidemiological data to identify strategic needs in
Indonesia
The first-ever Indonesian National Tuberculosis
Prevalence Survey in 2004 estimated that TB
prevalence, as determined by the number of
sputum-smear positive cases was 104 per 100
000, with regional differences in the Java–Bali,
Sumatra and eastern Indonesian regions. To
reduce this burden, the Indonesian Ministry of
Health used a variety of ACSM strategies to
identify specific populations that might benefit
from targeted outreach. A secondary analysis
used epidemiological data from the national
prevalence survey to identify the populations
by determining environmental and behavioural
risk factors of specific groups of individuals.
Results from the secondary analysis indicated
that people were more likely to be diagnosed
with TB if they were:
• older;
• living in the eastern provinces of Indonesia,
particularly in rural areas;
• men;
• living in urban areas;
• less educated; and
• living in a less “healthy” house (for example,
a house with poor illumination and ventilation
or no septic tank, sewage system or trash
management).
Study results indicated that the risk of TB
infection in children was two times higher
if their family history included contact with
people with TB, compared to families with no
contact. Children from lower-income families
were less likely to obtain TB medicines
compared to children from higher-income
CASE STUDY no. 1
families, probably because of the availability
of disposable income to pay for the medical
consultation and other costs associated
with care. (Anti-TB drugs themselves are
supposed to be available free of charge.) As
a result of this epidemiological investigation,
the Indonesian strategic plan to Stop TB
2006–2010 focuses on expanding DOTS
in the remote eastern provinces specifically.
This plan was designed to reach underserved
populations through social mobilization
and one of its six objectives is to increase
community participation in implementing
the TB control programme and increase the
demand for good-quality TB diagnostic and
treatment services.
To raise awareness of TB, especially among
key groups, Indonesia plans to form a strong
network of TB communicators over the next
five years. Mass media campaigns will use
culturally tailored TB messages with the aim
of strengthening the ability of patients and
communities to demand access to good
quality TB services and mobilize support for
TB control. These grassroots campaigns are
expected to significantly increase the use
of TB diagnostic and treatment services,
especially in the hard-to-reach eastern region.
To fill knowledge gaps related to TB, various
communication materials (brochures, posters,
leaflets and audiovisual materials) will highlight
important topics such as TB prevention for
children in families where at least one family
member has already been diagnosed with
TB.
ACSM for Tuberculosis Control: A Handbook for Country Programmes
Chapter 3:
Maximizing skills through
partnerships
By the end of Chapter 3, the reader will understand the
importance of collaborative management skills to:
1) identify and involve stakeholders;
2) assess and build capacity and resources;
3) assign roles and responsibilities;
4) manage partnerships;
5) create and manage budgets.
To carry out ACSM activities successfully, it is important
to review the unique skills and resources that the NTP
already has, then assess what additional skills might be
needed and how to obtain them. Because TB is such a
multisectoral, multilevel health problem, effective TB control
programmes must establish and nurture partnerships to
maximize contributions from different organizations. The
NTP might want to consider hiring specific ACSM staff with
management skills to lead these activities.
Decentralized health services also require planning
and managing ACSM at district and community levels.
Evidence and experience suggest that the scarcity of
skills in ACSM at the district level contributes substantially
to implementation problems. In addition, staff at public
and private health institutions, NGOs and community-
based organizations need technical support in planning,
implementing, monitoring and evaluating ACSM.
There are several steps to maximize collaboration, such as
the following.
1. Identify and involve stakeholders
The first step in collaborative management is to identify and
involve stakeholders. In addition to the NTP, organizations
of people affected by TB, technical institutions, donors
and private organizations are also involved in TB control.
Collaborating with these organizations is crucial because
in many countries the NTP may not have the resources,
knowledge nor the capacity to develop and carry out
ACSM strategies and activities.
Sometimes ACSM skills and resources may be found in
organizations outside the health arena. It is worth while
considering whether such groups – with insight into local
social and cultural approaches based on knowledge from
working and empowering communities – could either help
and participate in TB activities or even be brought in as
consultants to strengthen the local and national capacity
for ACSM.
09
SECTION 1: Preparing to take action
If an official partnership with other organizations is formed,
the NTP does not have to lead it. This could be done by
one of the other organizations in the partnership that has
appropriate experience.
2. Assess and build capacity and
resources
Stakeholders and other organizational partners come with
skills, experience and resources. It is important to assess
the types of skills, strengths and other resources available
among these partner organizations and to assess any
deficiencies or needs within the partnership that should be
addressed and filled.
Meanwhile, to avoid duplication of effort, research any
related activities that partner organizations or others may
be conducting in the country. Some assessment questions
are outlined below.
• Does a TB partnership already exist in the country?
• What existing platforms or programmes (such as HIV/
AIDS or malaria programmes) could be built on?
• What resource groups – such as media professionals,
production agencies, patient organizations, NGOs and
other professional groups in the country – could help plan,
develop and implement ACSM?
• Is money available for TB activities in the country?
What sources exist?
The 10-year framework recommends seeking support (skills
and finances) from multinational and national commercial
corporations. Such public–private partnerships can benefit
NTPs substantially and provide good public relations for
the corporations concerned.
At the same time, TB advocates must have access to
technical advice from appropriate agencies to build and
sustain ACSM capacity. This may include contacting the
public relations/communications staff from the ministry of
health, United Nations organizations and other specialized
ACSM training agencies to assist either with data collection
and access or with implementing activities.
3. Assign roles and responsibilities
Developing a partnership plan helps in assigning roles and
responsibilities to the various stakeholder organizations.
Responsibilities can include running the day-to-day
functions of the ACSM initiative or organizing a specific
event. Institutions should lead activities related to their own
particular area(s) of expertise. Specific responsibilities for
partners could be to:
• participate in strategic planning and in designing ACSM
activities;
• create a plan for monitoring and evaluating activities;
• make connections with political leaders;
 10 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 11
SECTION 1: Preparing to take action

SECTION 1: Preparing to take action

• give presentations to key decision-makers;
• create advertising about the programme’s priority themes
and messages;
• purchase advertising time and space;
• underwrite communication materials or activities
developed with the NTP;
• print, promote and distribute materials;
• sponsor publicity and promotional activities;
• develop a list of key media contacts;
• develop relationships with health reporters and other
media contacts;
• engage TB-affected community members in the
development and implementation of ACSM activities.
A staff member should be designated to identify
and involve stakeholders and coordinate roles and
responsibilities.
4. Manage partnerships
The person selected to coordinate work with all partners Create and reinforce positive expectations by providing information on the partnership’s progress. Optimism
should be: and success sustain member interest; report even small successes.
• a good time-manager who is able to balance several
components of ACSM initiatives at once;
• a team player who is:
- able to work with other organizations;
- willing and able to negotiate;
- willing to share credit for success. Formalize accountability and develop criteria for judging whether partners are honouring their
commitments.
Above all, frequent two-way communication is essential
to productive partnerships. Following are some guidelines
that can be used to create and maintain successful
partnerships. Space is provided to write some thoughts on
addressing them.

Be flexible about partners’ needs and constraints. Losing prospective partners by not making compromises or not
If possible, formalize the relationship to create greater commitment. Formal arrangements include written considering an organization’s needs can limit the effectiveness of interventions and activities.
memoranda of understanding, by-laws, mission statements and/or regular reminders of the partnership’s purpose and
progress.

Provide training to help members complete their tasks. For example, partners may need to learn how to be
effective advocates for programme issues.
Make the responsibilities of each organization and its staff clear. In particular, people need to know who will give
direction. Consider writing sample job descriptions or draft a memorandum of understanding for each partner.

Involve members in the ACSM endeavour and in decision-making. Also give them credit for successes and
Structure aspects of the partnership’s operation. Consider electing officers, forming standing committees or
other tasks that they accomplish.
having regularly scheduled meetings with written agenda and minutes. Expect and support action, not just discussion,
at these meetings. Circulate action items that result from meetings among partnership members. Follow up to make
sure all partners have accomplished their action items; this will foster greater ownership of activities and promote
accountability. Establish communication channels and use them frequently.

Evaluate the effectiveness of the partnerships periodically and make necessary changes. Conduct a process
evaluation of how the partnership functions and assess its impact on the health problems being addressed.

Involve people who show leadership characteristics, such as the ability to obtain resources, solve problems
and promote collaboration and equality among members. Members with political knowledge, administrative or
communication skills, access to the media and to decision-makers can also be valuable.
 12 ACSM for Tuberculosis Control: A Handbook for Country Programmes
SECTION 1: Preparing to take action
As with most aspects of ACSM activities, working with
partnerships is not static. Programme officers should
always be looking for – and considering – new partnering
opportunities.
5. Create and manage budgets
It is important to create a realistic ACSM budget at the
beginning of the partnership. This should reflect pre-planning
and intended activities. Partners should understand the
overall budget for the activities as well as the budget for the
respective components in which they are involved. Make
sure adequate funds are allocated for:
• meeting and work space;
• formative research;
• material and product development (including pre-
testing) and production;
• material distribution and storage;
• staff and consultants (specify the amount of time
needed);
• revisions to materials and activities, based on feedback
from implementers;
• process and outcome evaluation;
• payment of external technical or creative experts as
needed;
• miscellaneous costs of the partner organizations such
as transportation, telephone and postage.
It is also helpful to prioritize programme activities in case
funding is reduced. Make a breakdown to show the steps
involved in each activity that is being considered; provide
resources for each step.
Partner organizations can augment existing resources in
various ways. For example, some partners might be able to
contribute by photocopying materials while others may be
able to donate office space for meetings. When planning
ACSM activities, draw up a checklist of activities, products
and other resources that might be needed. If the NTP does
not already have some of these services or items, identify
potential organizations that might be willing to donate
them.
ACSM for Tuberculosis Control: A Handbook for Country Programmes
Private sector collaboration in Cambodia
The Pharmacists Association of Cambodia (PAC) is
the NTP’s main private-sector partner in Cambodia.
PAC’s role has been to mobilize registered
pharmacies and encourage pharmacists to identify
and refer people suspected of having TB to DOTS
services. PAC also facilitates pharmacy staff
training, oversees monthly supportive supervision
“It is important to activities, and coordinates and communicates with
create a realistic the public sector within the operational districts
where the project is active.
ACSM budget at
the beginning of the PATH provided technical assistance to strengthen
the PAC team – four staff members led by a
partnership. This senior member – in project management, project
implementation and advocacy. This assistance
should reflect pre- included the development of strategies, workplans,
planning and intended PAC terms of reference and the budget.
activities.” The municipal health department, which
regulates all private-sector activities, developed a
memorandum of understanding with the NTP early
in the project. The memorandum of understanding
stipulates that each pharmacy agrees to:
1) participate in the DOTS activities of the TB
public–private mix network in Phnom Penh;
2) cooperate with NTP, the municipal health
department, operational districts and related
organizations until the end of the pilot activity;
3) participate in training and workshops
related to Stop TB;
4) in accordance with national TB guidelines,
provide and disseminate accurate information
about TB to people suspected of having the
13
SECTION 1: Preparing to take action
CASE STUDY no. 2
active disease;
5) refer all clients with potentially active TB to
a public health facility providing TB services;
6) complete the referral coupon before
referring any client to a service;
7) keep records of any referrals made and
provide this information to project coordinators
every month; and
8) agree to be supervised by the project
coordinators and staff of the operational
districts, the municipal health department and
partner organizations.
During an orientation workshop, the memorandum
of understanding is shared with the private-sector
pharmacists who provide feedback.
The revised memorandum of understanding
between the municipal health department and the
providers is signed at the start of each training
session. It is also used by the PAC team as a tool
to measure performance during supervisory visits.
The use of the memorandum of understanding
as a management and monitoring tool has been
adapted by the provincial health departments
and is now used by all private providers in the TB
public-private mix network.

Core development process
Chapter 4:
Conducting a situation /needs
assessment
By the end of Chapter 4, the reader will know how to
conduct a situation or needs assessment for ACSM
activities by:
1) identifying challenges, priority populations and key
behaviours
2) relating “ideal behaviours” and goals
3) identifying factors and activities to enable ideal
behaviours
4) considering the assets and context of partners and
related programmes
5) considering the research methodologies that will be
needed
6) using assessment findings
7) creating strategic objectives for ACSM.
Before planning ACSM activities make an assessment
of the needs. The Stop TB Partnership’s advocacy and
communication checklist can be used in assessing these
components of the NTP. Reviewing this checklist (see
Annex B) might help identify strategic ACSM activities.
The needs assessment process should begin by identifying
the challenge to be addressed. This important first step
enables programmes to focus on the types of information
that need to be gathered, the types of populations they
want to focus on, the key behaviour they want to affect –or
the changes they want to effect – and how best to promote
change.
1. Identifying challenges, priority populations
and key behaviour
Many challenges identified in Chapter 2 can be addressed
by ACSM. Once the NTP identifies the challenges to
address, the next steps are to identify priority populations
to reach with advocacy, behaviour-change communication
and social mobilization efforts.
SECTION 2
NTP staff members have often targeted groups where
TB detection and control rates need to be improved. In
many countries, the populations most at risk of catching
TB include individuals suffering from narcotics addictions,
indigenous groups and ethnic minorities, migrant workers
and people living in poverty, in prison or with HIV/AIDS.
The following questions help determine which populations
should be influenced to change.
• Which populations have the highest rates of TB?
• Which groups usually delay diagnosis or treatment – such
as drug/alcohol users, indigenous populations, homeless
individuals, migrant workers, people in prisons/jails or
people living in poverty?
• Which individuals begin DOTS but often do not complete
treatment?
• What common factors are present in programmes where
individuals are diagnosed, begin DOTS, complete their
treatment and are cured? What has worked, why and
how?
Answers to the following questions can help guide TB
advocacy efforts.
• Which individuals can either change policies or allocate
funds for TB prevention and control?
• Who has supported or opposed TB control efforts? What
have these individuals said publicly?
The following questions will obtain information to inform
social mobilization activities.
• Which communities have large populations affected by
TB? How have these communities been affected by the
high rates of TB? Describe the characteristics of these
communities. Identify respected community leaders or
social organizers.
• Do medical/health service facilities exist in the community?
What services and care do they provide? What TB services
do they provide? Who visits the health centres?
• Where do people learn about health issues? Where do
people gather when they have questions? Who do they
ask for information? Do local media or other news sources
exist?
• Do any businesses in the community employ large
ACSM for Tuberculosis Control: A Handbook for Country Programmes
numbers of people? If so, have these businesses provided
any TB screening, treatment or resources?
Once information on the priority groups has been gathered,
ACSM planners must determine how to engage the
populations effectively. Planners identify key behaviour
that affectsTB; they then examine the factors that motivate
people to change as well as the barriers they may encounter
in making such changes. Other factors not related to a
patients’ behaviour, such as poorly trained health-care
workers administering DOTS, can also contribute to the
problem.
The table on p.16 provides questions– with space to write
the answers – to help analyse key behaviour in identified
populations. Create a separate table for each population/
group.
Answering the above questions may help to rule out certain
segments of the population. This should make it easier for
a programme to decide on message development and
dissemination and to ensure that programme resources
are spent effectively.
In some cases, initial research and assessment of information
needs may have uncovered adequate information about
the affected population, particularly if knowledge, attitude
and practice (KAP) surveys or other behavioural studies
have already been conducted. For ACSM interventions,
KAP survey results can help identify key behaviours. If
there is not enough existing information about the affected
population, the NTP team will need to decide what types of
information may be needed and determine how to obtain
it. This could be something simple like interviewing or
observing people in the affected population.
2. Relating “ideal behaviour” to goals
It is helpful to determine how “ideal behaviour” relates to the
overall goals of the NTP or ACSM activities. For example,
the ideal behaviour of going to a health-care provider at
the first signs of possible TB infection relates directly to
the NTP goal of increasing the case-detection rate for
TB. Planners should make sure that the ideal behaviour
they want to promote in their messages and activities is
somehow connected to the goals of the NTP.
Some examples of “ideal behaviour” are outlined below.
For the general public or at-risk populations:
• going to a health-care provider at the first signs of possible
TB infection;
• going to the proper facility to get tested for TB if a family
member, friend or someone they work with has the disease
or if they have been exposed to the disease in other
ways;
• initiating and completing DOTS treatment if they are
diagnosed;
15
• taking medicine every day, even after they feel better;
• practicing good hygiene, like covering the mouth when
laughing or coughing.
For health-care providers:
• following the correct protocols for treatment of TB – this
includes knowing how to administer DOTS and what
treatment path to take in the case of MDR or XDR TB;
SECTION 2: Core development process
• following proper infection-control procedures in the
health-care facility;
• counselling people with TB on the types of behaviour
that will prevent the transmission of the disease to others
(e.g., covering the mouth when they laugh or cough) and
providing guidance on how to best comply with the TB
treatment.
The cough to cure pathway helps identify ideal behaviour
and factors that affect it. This tool lists the ideal steps to
take, from the identification of symptoms to the completion
of treatment, such as to:
• seek timely care;
• go a DOTS facility;
• get an accurate diagnosis;
• begin treatment;
• persist in getting treatment; and
• complete treatment.
The cough to cure pathway shows how the interrelationship
between individual behaviour, social factors and DOTS
services affect treatment-seeking and completion. It also
identifies the individual, group and system barriers or
facilitating factors that may hinder or help an individual’s
ability to complete each step. Annex A has more information
on the cough to cure pathway.
3. Identifying factors and activities to enable
ideal behaviour
The cough to cure pathway can also help in identifying
motivators or enabling factors that facilitate an intended
behaviour change or barriers to ideal behaviour.
• What influences a person with TB to stay on, or veer off,
the cough to cure pathway?
• What are the barriers to continuing along the pathway?
• Do any personal, social and/or system-wide obstacles
exist (e.g., does TB stigma or a lack of nearby health
facilities prevent people from seeking diagnosis or care)?
• Are the knowledge, attitudes or practices of the people
with TB or the health providers preventing people from
completing the pathway (for example, do people neither
recognize the symptoms of TB nor know that they should
seek care in the first place? When do people begin to feel
better? Do they consider themselves “cured” and stop
treatment before the DOTS regimen is finished?)
 16 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes
Identifying what people care about also helps in tailoring
- What ACSM objectives are realistic for the target population? messages and interventions to resonate with the group in
- What is the behaviour or policy that needs to be changed? question. For example, in a culture that places a great value
- How willing is this population to make that change? on caring for family members, messages can emphasize
Note: In many cases a population cannot make a behaviour change until a policy change is instituted or a new or the importance of staying healthy, and getting diagnosed
improved product has been developed. If the NTP cannot affect (or effect) the change that might be needed (such as and treated, so as to be better able to take care of the
development of new treatments for TB), consider other priority groups or objectives. family. If a population trusts traditional healers, messages
might state that these individuals endorse DOTS. Or, if
certain people tend to avoid care in public health facilities,
SECTION 2: Core development process
messages can emphasize that care can be obtained at
specific types of private sector facilities.
ACSM activities need to enable ideal behaviour. This means
that a variety of activities should be undertaken to address
the diversity of barriers to TB prevention and control.
- Will achieving this/these ACSM objective/s [as identified above] with this population contribute to attaining
the TB programme goal? As a general rule, advocacy activities aim to address:
- Will the desired changes in behaviour, policies, funding levels or other objectives make a worthwhile
contribution to programme goals? • structural or systemic issues (such as the lack of
community DOTS programmes);
• communication interventions;
• individual and social barriers (such as stigma, risk
perception and knowledge among populations and health
staff); and
- To what extent would members of this population benefit from different ACSM interventions/efforts? Note: • social mobilization activities that promote changes
Some parts of the population may already engage in the desired behaviour or may be on the way toward implementing throughout a community or priority group.
a necessary policy change.
The activities chosen, whether in the areas of advocacy,
communication or social mobilization, should mean
something to the people who are to be influenced or
affected. That means reaching these people where they
already are. For example, when education on TB treatment
- How effectively can this population be reached through available resources and channels? is needed for migrant populations, communication activities
- Will mass communication (e.g., mass media, public events) reach the intended population best, or will and materials should be provided where the migrants live
something more interpersonal – like one-on-one skill modelling – better help these individuals make a and work, through people they interact with on a daily basis,
change in behaviour, opinion or policy? and not at clinics. Such a strategy has been employed
successfully by HIV/AIDS programmes in educating truck
drivers about HIV prevention at highway truck stops or
roadside clinics.
Chapter 5 provides additional guidance on how to match
activities and strategies to goals; it also describes examples
- To what extent do other populations influence the primary priority group? of activities that can be used to meet the goals.
- Whose opinions matter to the group being influenced? Is it possible to influence them?
4. Considering the assets and context of
partners and related programmes
To maximize available resources and increase the impact
of ACSM activities, consider what partner organizations
- To what extent can progress be measured? can contribute. Partners and related programmes (such
- Is it possible to gather information on the desired change? as HIV/AIDS programmes) can offer useful platforms from
Note: It is relatively easy to gather information in the case of policy changes, increases in funding or passage of new which to launch ACSM activities or distribute material; their
laws. It might not be as easy to measure whether misconceptions related to TB still abound. (For more ideas on ways existing activities may also be used to reach people with
to measure progress, see Chapter 9.) TB. Consult members of the Stop TB Partnership first.
Also, consider:
17
• organizations and individuals that may have a
connection to priority populations such as community
groups, faith-based organizations, local schools and
universities, professional organizations, traditional healers’
groups, women’s unions and youth unions;
• the regional office of the International Union Against
Tuberculosis and Lung Disease; and
• TB patient–activist associations that may have valuable
SECTION 2: Core development process
experience working with stakeholders and networks and/
or access to community resources.
An often-neglected source of support is the private health
sector. In some countries, people are increasingly going
outside public health facilities for diagnosis and treatment
for various illnesses. Private sector providers (both “for-
profit” and “not-for-profit”) are often geographically and
culturally closer to the community than the state-run
services. Engaging with these private providers and
building on their existing assets and networks might help
to make ACSM activities for TB sustainable and allow for
greater geographical impact.
Organizations that could assist with advocacy, social
mobilization and information-dissemination activities could
be the large-scale networks of national/international NGOs
and civil society organizations that are actively fighting
poverty and working to address the Millennium Development
Goals, such as the Make Poverty History campaign. Other
coalitions of organizations that could assist with advocacy
and social mobilization or, at least, serve as a source of
experience and “lessons learnt”, include NGOs, trade
unions and community-based groups that may also be
engaged in national and regional interventions to address
the Millennium Development Goals.
5. Considering the research methodologies
that will be needed
Several research methodologies can help programme
planners identify problems, resources and strategies.
Quantitative and qualitative methods differ in their
respective underlying approaches, tools and techniques.
Participatory assessments engage respondents in shaping
the questions that will be asked.
Quantitative methods include surveys on knowledge,
attitudes and behaviour. Closed-ended questions are asked
through questionnaires distributed to a random sample of
individuals. The individuals questioned can be from target
populations and sometimes from a control group also.
Qualitative methods focus less on precise measurement
of predetermined questions and more on a holistic
understanding of complex realities and processes. The
methods include focus groups, informal interviews, in-
 18 ACSM for Tuberculosis Control: A Handbook for Country Programmes
depth interviews, participant observation and visual media
such as photography and video. Questions are broad and
open ended; they change and develop over time.
Participatory assessments are particularly useful
when trying to promote change at the community level.
Participatory assessments ensure that the social, cultural
and economic conditions of the community are included.
By sharing in the selection and design of research projects,
SECTION 2: Core development process
communities gain skills and are in a position to make use
of the results in future health-care activities. In this way
important health issues can be activated and sustained by
the community.
6. Using assessment findings
Consider how the assessment findings can be used for
ACSM activities. Some uses are described below.
Use findings in advocacy
• Integrate KAP statistics into TB information materials and
media packages distributed to mass media, journalists
and key decision-makers.
• Educate political leaders and encourage them to draw
attention to the fight against TB-related stigma in their
public addresses.
• Show knowledge gaps or identify populations with
special needs.
Use findings in communication
• Create specific messages to inform the public about TB
and the benefits of completing treatment.
• Design interpersonal communication and counselling
training for health workers.
• Develop educational materials and messages to
encourage family members of people with TB to take an
active role in care.
Using findings in social mobilization
• Raise awareness of TB prevention, symptoms and
treatment by ensuring that programme staff go to
community events that are well-attended by people at
high risk of TB.
• Generate community dialogue during village or
community meetings to discuss factors affecting TB
diagnosis and care.
• Employ the media channels that the KAP survey has
identified as the most accessible and preferred by
members of the group you want to reach.
ACSM for Tuberculosis Control: A Handbook for Country Programmes
7. Creating strategic objectives for ACSM
A strategic objective states how a goal will be achieved.
A few example strategic objective statements are given
below.
• Increase awareness of epidemiological status of TB and
the sociodemographic profile among decision-makers in
governments.
• Increase support for TB services among local leaders.
• Increase knowledge of TB care services (the location,
no costs involved) among specific populations, such as
miners or seasonal migrants.
• Reduce stigma related to TB and people affected by TB
in peri-urban communities.
• Increase knowledge of “incentive programmes” (e.g.
transport and food vouchers) offered by TB services
among rural populations.
• Increase risk perception of TB in specific
neighbourhoods or areas with high rates of TB but low
diagnostic and treatment rates.
• Educate maternal health clinic workers to know how
they can incorporate TB services into their programmes.
Statements such as the above can be used to develop
messages and activities, and to help remind the NTP and
partners of the goal of ACSM efforts.
“By sharing in the
selection and design
of research projects,
communities gain skills
and are in a position to
make use of the results
in future health-care
activities.”
Needs assessment to support implementation of the
national TB programme in Ukraine
In Ukraine, the TB programme’s needs
assessments collected data through quantitative
and qualitative methods. Baseline data from
several specific populations residing in Donetska
oblast and Kyiv city were collected to assess
programmatic gaps in the implementation of the
NTP. This formative research aimed to explore the
needs, behavioural practices, and knowledge of
select populations, clarify the best channels and
formats for providing TB information, and evaluate
client satisfaction with the performance of their
doctors. The assessment techniques included:
• a KAP survey among the general public and
among open market vendors, food bank clients
and former prisoners;
• focus-group discussions with people living with
HIV and AIDS; and
• an exit survey among patients undergoing TB
care.
The exit survey focused on evaluating client
satisfaction with client-provider communication.
Patients often cited poor interaction with providers
as a reason for the delay in seeking TB diagnosis
or for stopping TB treatment. They suggested that
establishing rapport between the health worker
and the patient was a critical element of the
communication activities of TB control. Effective
communication depends on the patient’s ability
to understand the terms the health worker uses
and to respond in words and language the health
worker understands. The health worker must
treat patients with respect and sympathy, listen
19
CASE STUDY no. 3
to them and express interest in their welfare and
SECTION 2: Core development process
recovery, and simplify questions about issues
the patient may not understand. Most doctors
in Ukraine have never received counselling or
communication skills training and client-provider
communication does not include psychological
support and counselling.
Focus group discussions on TB services,
conducted with people living with HIV and
AIDS, identified a need to improve collaboration
and integration between the TB and HIV
services. The needs assessment thus led to the
development of a three-day training course in
effective communication and counselling for TB
doctors. This training covered: 1) interpersonal
communication, 2) steps in effective counselling,
3) counselling on TB, and 4) diagnostic counselling
and testing of TB patients for HIV. The three-day
course uses participatory methods including
role-play exercises with video playback and
discussion.
This course was given to TB carers in Kyiv city and
Donetska oblast and has been incorporated into
the national TB strategy as a key intervention to
reduce diagnostic delay, increase case detection
and improve treatment adherence.
 20 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 21

Chapter 5: The table opposite1 shows a few NTP goals and examples
of ACSM approaches and activities that can be used to
meet them.
NTP GOAL ACSM APPROACHES ACTIVITIES & CHANNELS

Designing ACSM interventions Gaining political

2. Assign roles, responsibilities and
By the end of Chapter 5, the reader will know how to:
coordinate activities
1) design effective ACSM interventions by matching NTP
As part of determining roles and responsibilities, undertake
goals with appropriate ACSM activities;
an honest assessment of available resources in the NTP
commitment for
• Educate national policy makers and
political leaders about the health and
• Seminars and briefing meetings
• Print information (letters, fact sheets)
TB control economic benefits of TB control. Aim to • Events around World TB Day and
have TB declared a national health priority other occasions.
• Educate local and community level

SECTION 2: Core development process

SECTION 2: Core development process

2) assign roles and responsibilities and coordinate

and among the partners. In many cases, an existing authorities to encourage them to contribute
activities;
platform such as an HIV/AIDS programme that provides
3) set and follow realistic timelines. to TB control efforts
resources or counselling to people co-infected with TB
and HIV (or their caregivers) or a health-related seminar • Solicit support of international and
1. Design effective ACSM interventions for policy-makers, can be used to conduct activities and national partners
by matching NTP goals with appropriate distribute messages on TB. The NTP should draw up a
table to show the roles and responsibilities assigned then
ACSM activities
ensure that everyone involved in the activity has access to
Linking ACSM goals with activities strengthens overall
it and agrees to their respective assignments.
programme effectiveness. Several ACSM approaches can
Improving case • Raise public awareness about TB • Formative research to determine
be considered for TB. Decisions on which approach or
A sample table to help coordinate various players and their detection • Reduce stigma against people with best messages and approaches
combination of approaches to use should take into account
responsibilities is provided below.
the benefits and risks, the time frame and the expertise and TB and correct misconceptions about • Mass media including radio and
financial resources needed for effective implementation. TB infection by actively involving current television
Annex C provides a list of ACSM goals (indicators).
and former TB patients • Distribution of print materials at
• Help health workers, communities community meetings or events
and individuals identify TB cases • Interpersonal communication and
Organization Contact Person/ Activities Timeline/Due Status • Encourage individuals to seek care counselling training for health workers
Name & Type Contact Information Responsible Date for from appropriate sources • Community mobilization activities
of Organization For Activities • Target hard-to-reach populations
(prisoners, urban poor, homeless)

1)

Increasing • Give people with TB hope of complete • Interpersonal communication and

treatment cure counselling training for health workers
2) success and • Encourage people with TB to seek • Mass media including radio and
discouraging the treatment from appropriate sources television
spread of MDR • Provide materials to counsellors • Extensive distribution of print
TB • Encourage people with TB to complete materials at health care facilities
3) treatment even if they improve before • Community mobilization activities
treatment ends • Peer education at community or
• Make people with TB aware of interest group meetings
possible side effects and where to seek
care if present
4)
• Encourage health workers, family and
community members to directly observe
people with TB taking their medicine
• Engage people who are fully recovered
to encourage people currently affected by
TB to complete treatment
1 Adapted from The Role of Health Communication in Achieving Global TB Control Goals: Lessons from Peru, Viet Nam and Beyond. Health Communication
Partnership, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, 2004.
 22 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 23

3. Set and follow realistic timelines
Allocate time wisely when designing ACSM activities.
Create a timeline with realistic expectations. Consider the
preparatory activities that need to be addressed first, then
identify the subsequent sequence of activities involved.
Estimate how long each activity will take.
Many factors can accelerate or slow down ACSM activities
message to people who have never heard of DOTS should
not encourage them to start treatment immediately. It
should rather focus on raising the awareness of DOTS with
the aim of moving the group toward getting treated. Look
at the stages-of-change model (in Annex E) to understand
the stages in changing behaviour: pre-contemplation,
contemplation, preparation, action and maintenance.
such as women’s unions or religious institutions, and 4. Developing a guide to use messages and
emphasize their involvement. When a message involves
using TB drug treatment, it is best to use a trusted and
concepts creatively
The next step is to create a “map” or “blueprint”, sometimes
unbiased source. If people perceive an ulterior motive,
called a creative brief, to give to implementers or creative
such as a pharmaceutical company with a profit-driven
staff – the writers or designers. The brief is to give simple
interest in the treatment, they may dismiss the message.
directions to help them create images, logos, designs and
messages that should connect with the target audiences.
It is good to ask representatives of the target group whether
Ideally, there should be a brief for each intended population

SECTION 2: Core development process

Even if a group is motivated by a message, other factors a particular messenger is well-liked and relevant to the
SECTION 2: Core development process

and must be considered when creating a timeline. Some
factors might include conflicting partner schedules and
unavailability, delays with producing and printing materials,
holidays or other observances, unexpected illnesses
among key personnel, and political transitions or civil
society unrest. Think about occurrences or conditions that
have created delays in the past, and factor those into the
timeline.
may limit their ability to adopt the proposed behaviour or take
the recommended action. For example, at-risk individuals
might not seek testing or treatment because they are afraid
of being stigmatized by their communities.
Accurate and clear messages are the most credible. Advice
and information on treating TB changes rapidly so scientific
accuracy is vital. This is particularly problematic with MDR-
TB and XDR-TB where recommended treatment regimens,
as well as access to treatment, frequently change.
issue. In many cases, the most effective messengers may
be members from trusted social networks such as clubs,
neighbourhood or other local groups.
3. Considering appropriate logos, slogans
and other creative aspects
Logos, slogans and other graphic representations can
help unite different ACSM activities that occur over a long
period of time. These creative elements will help establish
programme recognition and trust, while distinguishing
because it is likely that the messages will differ for each.
An effective brief summarizes what is known and allows
creative staff to identify several approaches that could
effectively convey the intended messages. A vague,
loosely worded brief can confuse the creative staff and lead
to poorly constructed messages and ineffective products
and activities.
A worksheet for compiling a creative or strategic brief is
provided in Annex F.

Chapter 6: Messages should be simple and contain very few, if any,

scientific terms. Include only information that is necessary
for priority groups to take the desired actions or decisions.
Developing ACSM messages Do not include information on disease physiology, research
its activities from those of competing programmes or
messages.
Wherever possible, use the same graphic identity in all

and concepts
By the end of Chapter 6, the reader will understand how to
develop messages and concepts by:
1) targeting messages appropriately;
2) using credible messengers of information;
3) considering appropriate logos, slogans and other
creative aspects;
4) developing a guide to use messages and concepts
creatively in ACSM materials and activities.
The TB messages disseminated should be consistent
and relevant across all channels and activities. The more
the messages reinforce each other across channels, the
better the results will be. Consistency makes the ACSM
strategy effective – ensure that the health-care provider,
the community mobilizer and the radio announcement
all give the same key information. This does not mean
creating only one message for everything. It means, rather,
identifying key points that every message should convey,
no matter how it is communicated.
1. Targeting messages appropriately
Messages must be relevant to the various groups they
target. Each group may have a different level of knowledge
of TB so target messages according to their respective
level. Messages should address the action or change that
the intended audience is ready to make – for example, a
debates or sponsoring organizations.
Consider the written and visual literacy levels of the target
audience. Many people cannot understand health materials
written in technical language, particularly if their literacy
skills are low. Make specific choices on the writing style,
vocabulary, typography, layout, graphics and colour. These
choices affect whether the message is read and how well
people with varying degrees of literacy will understand it.
2. Using credible messengers of
information
All messages conveyed should be credible. The audience
must trust whoever delivers the message – whether it is
someone in authority, a celebrity or a group member. It is
necessary to know who is trusted to give advice about
health or TB; the needs assessment should have gathered
this information. A person’s credibility will be linked to the
message he/she delivers. The right person to deliver a
message highlighting TB as a public health problem, for
example, might not be the appropriate person to deliver a
message on trying to reduce TB stigma. A celebrity might
be a good choice for the message on raising awareness
of TB, but a person cured of the disease would be a better
choice for the message on the stigma of TB.
Messengers can be individuals or organizations. TB
programmes can collaborate with credible organizations,
ACSM activities – for example, use the same or compatible
colours, types of illustrations and typefaces in all printed
materials. Include a logo in all materials. Graphics and
messages should not send different signals; they should
reinforce each other and follow the overarching ACSM
strategy. No matter how creative, compelling or wonderful
a slogan may be, do not use it if it does not fit with the “Logos, slogans
strategy statement, objectives and/or identified audience.
and other graphic
In developing a logo or a slogan it is necessary to consider
cultural norms associated with the images to be portrayed. representations can
The symbols, metaphors, visuals (including clothing,
jewellery and hairstyles), types of language and music help unite different
used in materials all convey aspects of a culture. Use ideas
that reflect local customs and ways of talking when you ACSM activities that
describe and identify TB.
occur over a long
It is important to acknowledge and understand a priority
group’s culture. It is not always necessary or even advisable, period of time.”
however, to develop separate messages and materials
for each different cultural group. Pre-testing messages,
concepts and images before they are distributed helps to
identify those that resonate across groups and to recognize
situations where different messages or images may work
better. The time spent to test and refine messages is
always worth while; it ensures that the messages and
images are well received, effective and, most importantly,
inspire positive change.
 24 ACSM for Tuberculosis Control: A Handbook for Country Programmes
A tale of a Kenyan family and TB
Kenya’s National TB Communication Strategy
SECTION 2: Core development process
promotes strong links between mass media,
interpersonal media and the community. In the
absence of known stakeholders and personalities,
a “virtual family” called the Rahisi family in a
fictitious Kenyan town has been created. The
Rahisi family members are expected to serve as
the official spokespersons for all communications
related to TB, appearing in all selected media and
materials.
The members of this family, through their
humorous interaction and conversations among
themselves and with their neighbours, friends,
doctors and others in the community, reflect a
range of predicaments related to TB in the age
of HIV/AIDS. Over the long term, the goal is for
the characters in the family to become culturally
popular spokespersons and demonstrate the best
possible response to TB risk and disease.
The family includes parents, at least one child
under the age of 10, and two adolescents (male
and female, between the ages of 16 and 24).
One develops active TB. The reactions of the
family exemplify both the thoughtful, questioning
approach to health and TB and also the irrational,
fear-based and life-threatening responses. All
CASE STUDY no. 4
exchanges rely heavily on humour to sustain interest
and allow for sensitive handling of death-related
issues.
The family’s scenarios are depicted in short role plays
(each less than three minutes in length) designed for
radio and closed-circuit television. Each scenario
explores a single aspect of TB or the response to
it. Clear, accurate information and motivational
success stories form the main content. Following is
a sample scenario.
I forgot my pill today: The forgetful father
and his assistant at work. Today the father has
forgotten nearly everything he needs: his wallet,
his handkerchief, his socks are mismatched,
his umbrella is at home, and he has forgotten to
bring his TB pills. His assistant lends him money,
a handkerchief, a new pair of socks and a spare
umbrella. But he tells him that he cannot give him
his missing TB pills. Just then the man’s school-age
son runs in with the pills saying, “Daddy, didn’t you
forget something important?”
ACSM for Tuberculosis Control: A Handbook for Country Programmes
Chapter 7:
Developing ACSM materials
In this chapter, the reader will learn how to develop effective
ACSM materials by:
1) understanding the cycle of developing materials:
draft–pre-test–revise;
2) identifying materials needed for different activities;
3) selecting appropriate materials;
4) hiring “experts” to develop materials;
5) pre-testing materials;
6) revising materials based on pre-testing and other
feedback.
1. Understanding the cycle of developing
materials: draft–pre-test–revise
Developing initial drafts of materials and pre-testing them
ensures that the messages are effective and reflect strategic
guidelines. Pre-testing allows planners to learn early in the
process which messages, products or activities will be
most effective with the intended population. Knowing this
will save time and money as it will ensure that ineffective
products are not mass produced and distributed.
Pre-testing helps NTP programmes to ensure that people
understand the messages in the materials and that the
intended population draws the desired interpretations. Pre-
testing also offers an important opportunity for communities
and other interested parties to become involved in the
ACSM process early on and to share what they believe
will work or not work. Communities or individuals affected
by TB should be brought into the process even earlier to
help create the materials. Staff and partners with technical
expertise should also be consulted to ensure that all
scientific and technical information is correct.
Once results from pre-testing have been compiled and
analysed, materials can be revised to reflect the feedback
received. While pre-testing can improve the effectiveness
of materials, there is no guarantee that activities and
supporting materials will achieve their intended goals.
Pre-testing can provide an indication of the strengths and
weaknesses of materials, but it cannot definitively determine
what will or will not work.
2. Identifying materials needed for different
activities
Several different types of materials can be developed to
support ACSM activities. Examples of materials required
for different activities are provided in the table on the next
page.
25
Selecting channels that will be effective in reaching intended
populations is important. Leaflets placed in clinic waiting
rooms, for example, will not encourage more people to
go to clinics to get diagnosed and treated for TB. Place
materials for intended populations in locations where the
target audience normally goes, such as markets, bus
stations, train stations, taxi and truck parks, schools, places
of worship, workplaces, union halls, community buildings
SECTION 2: Core development process
where meetings are held, and in front of the homes of village
elders or other places where people gather informally.
3. Selecting appropriate materials
Development and production of materials can be time
consuming and costly. Before taking this step, determine
whether new materials are necessary.
Communication materials such as booklets, leaflets,
posters, public service announcements and videotapes
may already exist; they may have been produced in the
planning phases. Check for existing materials through
clinics, the ministry of health, NGOs, trusted Internet web
sites and local universities. If you find any, decide whether
they are useful as they are or whether they need to be
modified.
In reviewing existing materials, ask the following
questions:
• Are the messages accurate, current, complete, and
relevant?
• Are the format, style, cultural considerations and
readability level appropriate for the targeted audience? If
not, could they be modified easily?
• Will the materials meet the communication objectives?
Pre-testing can help answer some of these questions. If
possible, check each item with the group that originally
produced it to find out:
• results of any pre-testing (be sure to ask which groups
the materials were pre-tested with);
• effectiveness of the materials to date;
• any advice or recommendations related to the
programme’s ACSM needs.
In deciding whether to use existing materials, ask the
original producers several questions.
• Are the materials available?
• Can the NTP have permission to use the materials?
Modify them? Would reprinting be easy?
• Are they affordable?
• How have they been used?
• How have they been received?
• Is there any information about their effectiveness?
 26 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 27

ACTIVITIES
Meetings with policy makers (e.g., meetings with
law makers to advocate for increased TB funding)
MATERIALS
Pre-test existing materials with the intended audience. Even
if the materials are not appropriate, you may gain valuable
information that will help in modifying them or developing
• Fact sheets new materials.
• Presentations, other visual aids such as slides,
photos, posters Developing new materials will probably be costly. Choose
formats that the programme can afford and make sure that
• Letters
there is enough money to print, distribute and promote
• Briefs that summarize data
5. Pre-testing materials
As mentioned, pre-testing materials helps to ensure that the
intended messages are understood. Although colleagues
can add useful input, testing the materials with intended
group members will give a sense of their reactions.
People who do the pre-testing may be internal or external
researchers, communication experts or members of the
creative team that has been hired or assigned to develop

SECTION 2: Core development process

sufficient copies to meet your needs.
SECTION 2: Core development process

the materials.

Outreach to media (e.g., to promote World TB Day,
awareness campaign)
Public awareness activities (e.g., increase
awareness/reduce misconceptions about TB, reduce
stigma)
Peer education and training (e.g., for health care
workers and communities to identify TB cases,
provide the proper care/treatment)
Presentations at seminars or other gatherings
(e.g., with decision makers or health care
professionals)
• Letters to the editor
• Opinion-editorial write-ups
• Press releases
• Public service announcements, live-read scripts/
announcements
• Summaries of key findings, articles (and authors)
• Informational booklets, leaflets/flyers, posters
• Radio and television spots (live-read scripts or
produced public service advertisements)
• Training modules
• Fact sheets
• Flip charts/flannel boards
• Instructional posters/wall paintings/job aids
• Videotapes
• Presentation slides or other visual aids such as
photos
• Displays (including posters, photographs, real
objects, models)
4. Hiring experts to develop materials Pre-testing is not necessarily expensive. There are low-
If the NTP decides to develop new materials, it might be budget methods and money-saving strategies to review
necessary to work with health communication or design materials among intended groups, such as those outlined
experts – either within the NTP or on a contract basis. below.
It might seem easy to design and create effective, eye-
catching materials that deliver the intended message(s),
but this is not always so. Materials might be technically
correct but, if the intended group does not notice or relate
to them, they will be ineffective. Managing the relationship
with the team of creative professionals and consultants is Lower-cost options for pretesting
therefore a critical factor in producing effective materials.
When working with an advertising agency or other external • Conduct focus groups in DOTS clinics with
consultant, consider the experience and previous products health staff and people living with TB.
of the professionals who will staff the effort. Additional • Share materials with TB “clubs” or other TB
guidelines on how to select and work with external groups.
advertising agencies can be found in a resource called How • Have communities or those affected by
to Select and Work with an Advertising Agency: Handbook TB design, develop and test materials and
for Population and Health Communication Programmes2. messages (for the general community).
The creative brief (described above in Chapter 6) explains
the ACSM strategy to ensure that the outside organization
understands the constraints and follows the instructions.
Consultants should understand the objectives and Other ways to reduce pretest costs
concerns of the NTP as well as all that has been learnt
about the intended population, particularly sensitive issues,
as well as key content points and other aspects that should • Work with partner organizations to recruit
be conveyed in the messages and materials. participants and conduct tests (e.g., a place of
worship, a clinic, patient educators’ clients).
Other issues to consider are the type of pre-testing and • When testing with many respondents, keep
approval that will be required, when the pre-testing will the questions short and focused; use close-
occur, how long pre-testing will take, how many rounds of ended or multiple choice questions as much
revisions will be made, and whether the creative consultants as possible (for easier analysis); and develop
observe the pre-testing. If they listen to the reactions and
codes in advance to quantify responses to
concerns of the target population it will help them develop
messages and materials that use appropriate language
open-ended questions.
and ideas. • Avoid over-testing (pretests should answer
questions, not gather new opinions).
Even if outside organizations are not used, the internal
team (ideally led by a communication expert) will need to
consider all the issues involved in pre-testing materials.

2 Available on the Internet at http://www.jhuccp.org/pubs/fg/2/2.pdf

 28 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Follow the steps below to plan and conduct a pre-
test:
A. Determine test objectives
B. Choose methods
C. Identify, screen, and recruit respondents
D. Draft test instruments (discussion guides,
questionnaires)
E. Conduct the pre-test
F. Analyse results.
SECTION 2: Core development process
A. Determine test objectives
Formulate research objectives for the pre-test. Write
specific objectives to provide a clear understanding of what
the programme wants to learn from whom. Pre-testing can
also help to answer questions about alternate ways to
present information, questionable inclusions or depictions
and reviewer conflicts regarding content, format and
appearance. Describe which segments of the intended
group should be included and/or excluded.
B. Choose methods
Several research methods can be used to test messages
and materials. The choice of method depends on the
research objectives, the materials, the target group and the
amount of time and resources available for pre-testing.
There are many different ways to pre-test concepts,
messages and materials with intended group members,
such as:
• focus groups (face-to-face or telephone for audio
materials);
• in-depth interviews;
• interviewer-administered surveys/questionnaires – by
telephone, through central-location intercepts, or other
face-to-face scenarios;
• theatre testing where a large group responds to
messages via questionnaire;
• observational studies paired with exit interviews – for
instance, observing how much time people spend
examining informational leaflets while waiting in a clinic
then, as they exit, asking what they learnt and whether
they found it useful;
• Readability assessments to see if printed materials are
easily understood.
“Gatekeeper” or expert reviews can also allow health
officials or leaders of the NTP to provide their input. Health
communicators often ask gatekeepers (e.g., partner
organization leaders, public service directors, physicians
and teachers) to review materials. This provides input from
people close to those who need to be reached and also
increases the likelihood that the gatekeepers themselves
will use the materials with the intended population. If the
graphic style or illustrations depart from what gatekeepers
3 The Handbook for Excellence in Focus Group Research by Mary Debus, available on the Internet at http://www.globalhealthcommunication.org/tools/60
or other reviewers expect, focus on this when testing
draft products with the intended group. Use favourable
responses from the pre-testing to persuade gatekeepers
to accept the selected approach. Gatekeeper reviews,
however, should not be used as a substitute for pre-testing
materials with members of the intended group.
Choose additional reviewers carefully. Reviewers may be
subject experts, communication specialists, representatives
of the intended group, TB control specialists and partners;
they should have relevant knowledge and represent a range
of expertise. In some cases, reviewers with other skills or
view points may be important, such as legal professionals,
law enforcement officials, social workers, school personnel
or clergy.
Explain exactly what reviewers are expected to do and what
they should not do. Give them guidelines, a list of questions
to answer for example. Do not be discouraged by too much
criticism, whether it is constructive or destructive. Keep in
mind that NTP and ACSM programme planners are not
required to act on all the comments received.
Allow sufficient time. Reviewers need time to do a thorough
job and the creative professionals require time to make
thoughtful and careful revisions.
C. Identify, screen, and recruit respondents
Develop guidelines on recruiting people. A sample of a
recruitment instrument is provided in Annex G.
Another useful resource is The Handbook for Excellence
in Focus Group Research3. Written to take into account
situations in developing countries, it provides a sample
screening questionnaire and other focus-group instruments
such as discussion guides and sample focus-group
reports.
Another helpful tool is a more recent publication, A Skill-
Building Guide for Making Focus Groups Work, produced
in 1955 by the Academy for Educational Development in
Washington DC, 1995.
D. Draft test instruments (discussion guides,
questionnaires)
Ideally, the creative team or communication expert
heading the development of materials should be involved
in developing the discussion guides or questionnaires
that will be used to ask questions and gather information
during the pre-testing. Questions should assess the areas
outlined below:
ACSM for Tuberculosis Control: A Handbook for Country Programmes
• Content: Understanding the content, accuracy of
information presented, credibility of the people expressing
themselves through the material, and the kind of reactions
evoked by the content.
• Form: The interest generated by the materials and the
technical quality.
• Materials: The reaction to formats that have been
used, the technical environment necessary to use the
material and the useful life of the material.
Annex H has sample guides for focus-group discussions
and Annex I has sample questions for pre-testing printed
and other materials.
E. Conduct testing
If possible, have the creative team, content experts,
partners and gatekeepers (including TB programme
decision-makers) present at some focus-group discussions
or interviews. Observations made during pre-testing or
concept exploration often pinpoint comments or recognize
trends that are important for the creative development of the
materials. These responses improve the team members’
understanding of an intended group’s reactions and can
illustrate, more vividly than any report, the need for simple
language or the power of a particular creative approach.
F. Analyse results
Use the test objectives set forth in Step A to analyse the
findings at the beginning of the process. Were the objectives
of the pre-testing met? Consider what was found and what
was not; sometimes what is not stated by a participant is
very important.
Avoid over-generalizing the findings. For example, if 50 of
100 respondents in an intercept test do not understand
sections of a pamphlet, it does not necessarily mean that
50% of the total intended group will be confused. The
lack of understanding among the pre-test respondents
suggests, however, that minor revisions may be needed to
make the pamphlet easier to understand.
A problem often encountered in analysing results is
the interpretation of the reactions of a respondent to a
sensitive or emotional subject, such as stigma related to
TB. Respondents may become guarded when reacting
to materials and hide their true concerns, feelings and
“A problem often encountered in analysing
results is the interpretation of the reactions of a
respondent to a sensitive or emotional subject,
such as stigma related to TB.”
29
behaviour. Those pre-testing and analysing the results
must therefore examine and interpret responses carefully.
6. Revising materials based on pre-testing
and other feedback
Revisions that will be made to materials are usually included
in a report on the testing process. Such a report should
comprise the sections outlined below.
SECTION 2: Core development process
• Background: Who was tested? Why? How? What
lessons or results were anticipated? Describe each in
detail.
• Highlights: Summarize the main points that emerged
in answer to the research questions during testing.
• Findings: Describe the findings. Where appropriate,
describe participants’ reactions, quote participants and
use examples from the test documents to support the
findings.
• Conclusions: Describe patterns that emerged or
significant differences observed between groups. If no
patterns are apparent, more research may be needed.
• Recommendations: Suggest revisions for materials or
planned approaches based on findings and conclusions.
• Annexes: Include copies of test instruments used,
such as discussion guides, screening questions and
questionnaires.
In most cases, the ideal person to prepare the report is a
team member with a health communication background.
If such a person is not available, the pre-test researcher
may be able to report on the findings but may not be in
a position to draft useful recommendations. Involve the
creative team to recommend solutions or revisions.
If major changes are made to a message or product, based
on the original pre-test results, consider pre-testing again if
resources permit. In most cases, however, revisions based
on the pre-test findings and the recommendations of the
communication or creative experts involved in the process
will not need to be tested again.
 30 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Developing IEC materials for health centre staff working
in TB programmes in Cambodia
To successfully implement DOTS, interactive
approaches that promote community participation
SECTION 2: Core development process
and discussion to raise community awareness of TB
prevention, diagnosis and adherence to treatment
are essential. Local health centre personnel, as
trusted and respected community members,
are ideally positioned to lead such awareness
activities.
With funding from the US Agency for International
Development’s IMPACT project, PATH provided
technical support to the Cambodian NTP’s
information, education, and communication
(IEC) team to develop a communication training
curriculum and handouts for public health-care
providers working in TB DOTS programmes. The
training curriculum seeks to strengthen providers’
interpersonal communication skills and promote
the effective use of supportive materials such as
flip charts and other health promotion tools to
educate people with active TB. It uses participatory
methodologies such as small group discussions,
games, case studies and practical sessions with
peer feedback.
PATH’s approach was to walk the NTP staff through
the process of developing IEC materials, following
five essential steps: 1) assessment, 2) message
development, 3) pre-testing and revision, 4)
production, and 5) dissemination and monitoring.
This approach enabled the NTP IEC team to build
its capacity to develop appropriate materials by
applying their newly acquired skills to produce a
final product that they could use.
Step 1 was to conduct an assessment with public
health-care providers to determine the kinds of
information and tools that would be preferred by
them. The assessment relied on focus-group
discussions and individual interviews and provided
information for step 2, the development of the
first draft of the curriculum and accompanying
tools. Step 3 was to pre-test the materials with
CASE STUDY no. 5
two different groups: one group, the health staff
working in DOTS programmes; the other, the
potential trainers. To do this, the team conducted
focus-group discussions during which the content
and duration of each session of the curriculum was
pre-tested and revised. They then conducted a
second round of focus-group discussions to review
the changes and finalize the content.
In step 4 a designer was hired and a mock-up
presentation of the curriculum was prepared. This
was pre-tested with the provincial and operational
district TB supervisors who would be the trainers.
Based on their feedback, the training curriculum
and handouts were finalized and shared with the
NTP manager, key ministry of health personnel and
relevant TB partners for their final approval. Following
this approval, the final versions of the curriculum and
handouts were printed and disseminated in step 5.
To develop the national IEC training team’s skills in
delivering workshops, PATH conducted a training-
of-trainers workshop using the curriculum and
handouts. Following this initial training, the IEC
team, with oversight from PATH, trained all the TB
supervisors in 24 provinces. Since 2006, the IEC
team, in collaboration with TB provincial supervisors
and with continued support from PATH, has trained
health staff working in DOTS in 15 out of the 24
provinces.
At the start of the training phase, a monitoring plan
was developed to allow continual adaptation of the
curriculum and handouts, based on feedback from
participants and the experience of trainers. This
ensured that the materials optimally meet the needs
of both groups. For example, a local NGO may adapt
the curriculum and accompanying materials for use
with community health workers. The materials can
be revised electronically and printed as needed to
minimize the costs. This capacity-building process
has produced a set of useful and popular tools that
can be easily adapted for specific uses.
SECTION 3
Implementation and
evaluation
Chapter 8:
Implementing ACSM activities
In this chapter, the reader will understand the steps required
to implement ACSM activities, including:
1) learning how to address logistics and the role of partners
during implementation;
2) understanding issues related to launching activities.
1. Learning how to address logistics and
the role of partners during implementation
When implementing ACSM strategies, pay attention to
logistical details – the “how,” “when” and “who” – of planned
activities. Many details can be addressed and coordinated
by TB programme staff. Planners will also coordinate
with partner organizations and volunteers to carry out
activities successfully. Before officially “launching” ACSM
activities, planners should produce an implementation plan
that addresses the three key areas: partner roles, public
relations and distribution issues.
ACSM activity Organization
responsible /
contact person
Partner roles
Planners should define the roles, relationships and
responsibilities of all implementing partners. This will avoid
misunderstandings and ensure that expectations are
realistic and achievable. Such coordination will maximize
resources and synergies between partners while avoiding
duplication.
All organizations need to know who is responsible for
the different tasks involved in rolling-out communication
activities, including distribution, funding procurement,
information systems, management, monitoring and
evaluation, resource allocation, supervision, training and
other functions. Organizations collaborating as part of a
network, coalition or “franchise,” should be included in this
planning.
The table below can be used to plan what needs to be
done, who/which organization will lead each activity, when
an activity needs to be initiated or completed, and the
types of materials or resources and support that might be
needed.
Activity start date Materials and Status
& completion other resources
date needed
 32 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Not all NTP staff members will know the details of the planned
ACSM activities. All staff and partners should be informed
of the ACSM interventions and should review the roles of
each organization. For example, if nurses are supposed to
give an educational brochure to clients, they need to know
how best to incorporate the brochure into visits or in their
interaction with clients. Clinic managers might need to be
explicitly told to put posters up and set brochures on the
tables in the waiting rooms. Do not assume that everyone
knows what to do, even if it seems obvious.
Clear expectations and communication about what
partners will do, when and how they will do it are critical.
NTP staff should work closely with partners to prepare for
implementation. Partners should be given tasks that are
reasonable; the easier it is for the partners to participate,
the more likely it is that they will complete their assigned
tasks. Partners should have copies of materials, talking
points, display racks for brochures and other aids. Most
importantly, planners should listen to and address partners’
suggestions and concerns where possible, acknowledge
partners’ contributions and thank them publicly when
appropriate.
SECTION 3: Implementation and evaluation
As activities continue, a regular coordinating mechanism,
such as weekly or monthly meetings, should help partners
assess and maintain progress. Informal communications
can also track activities.
2. Understanding issues related to launching
activities
Outreach to the public can be a major part of launching
ACSM campaigns or activities. Many organizations hold a
“kick-off event” to introduce their activities to the media and
the community. This can be a press conference or any
other event that spotlights the TB situation and programme
and motivates public commitment from national and global
authorities.
Other launch events could include activities such as:
• a walk or parade
• a health fair
• an expert panel discussion including people living with
TB
• a concert/entertainment event
• a disease-screening event
• a celebrity appearance.
The event should meet three criteria: it must attract
members of the priority populations; it must communicate
key messages; and it must be considered sufficiently
ACSM for Tuberculosis Control: A Handbook for Country Programmes 33
newsworthy by the media for it to be covered. Planners
should decide in advance which media outlets to target Who are the partner organizations and how do they contribute to the programme or ACSM activities
– local or national outlets, television or radio. specifically?
Designate one partner (or person) – and a backup – to
address and respond to potential questions from partners
and communities. This person, in most cases the NTP
director, can serve as the programme’s spokesperson.
Do additional partner organizations and volunteers need to be recruited to carry out activities?
He/she should be prepared to respond as needed and
should ideally have some training in media relations that
offers guidance on how to effectively communicate with
journalists and other members of the news media. Skills
in media relations can also help in talking to journalists,
to interest them in covering the events and perhaps even
becoming partners or advocates of the cause. Direct all What are the dissemination activities or platforms? Confirm that they are still viable and appropriate.
calls or communications that require any type of public
comment to this person.
Create talking points to help the spokesperson(s) to explain
to the media and others who might ask questions about
why the activity is taking place.
Will radio, television or other media materials be given to media outlets, either as public service
Talking points can include other information such announcements or as paid advertisements?
as:
SECTION 3: Implementation and evaluation
• facts about TB, including local statistics
• how the programme is addressing the problem
• why these approaches have been chosen
• responses to foreseeable objections to activities and How many copies of each product will be needed? Estimate the potential demand. Produce enough copies
interventions. to be able to replace the materials as they are used up.
If there is news coverage, planners should be prepared
to provide follow-up information; if the coverage conveys
anything incorrect or misleading, they need to talk to the
media and clarify any misconceptions. Even if there is no
follow-up to provide or misconceptions to clarify, it is still Is there a plan for tracking inventory?
advisable to contact the reporters covering the event and
thank them for their interest. This helps to build a relationship
with the media that can continue to be useful in promoting
the programme’s activities.
Distributing materials is another key part of a launch. Is there a place to store supplies?
Consider the issues opposite.
Does everyone on the team know how to distribute the materials? Clearly state what needs to be done with
materials so that they do not get forgotten, unused, in a box.
 34 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Implementing ACSM in Kenya
The National Leprosy and Tuberculosis Control
Programme (NLTP) of Kenya, the custodian and
primary stakeholder on all matters related to
TB control and prevention, has approached the
subject of ACSM holistically. Recognizing that
the needs, approaches and target audiences of
advocacy and communication are significantly
distinct from each other, the NLTP began
development of a national TB communication
strategy and a national advocacy strategy in
2003.
The national TB communication strategy drew
from, and built on, TB assessments and research
dating back to 2002. In the absence of a national
KAP survey, several community-level workshops
SECTION 3: Implementation and evaluation
were conducted to allow the NLTP to gain
qualitative insights into knowledge and attitudes
to TB, especially in relation to HIV. These
workshops led to a draft TB communication
strategy that was validated by a multilevel review
process.
This review and validation process engaged TB
stakeholders from different levels of government,
civil society and the nongovernmental sector. Two
national-level review workshops brought district
and provincial-level TB staff together – one was
held in Nairobi, the other in a province. In a
CASE STUDY no. 6
three-day process, participants in the workshops
went over the strategy document word by word
and made recommendations and changes. The
Interagency Coordination Committee of the NLTP,
whose members include donors and implementing
agencies, reviewed the strategy drafts at the
penultimate stages.
The final national TB strategy document, entitled
Lights of Hope, provides a broad and evidence-
based framework that allows the NLTP and
other NGOs communicating on TB and HIV to
align themselves with national objectives and to
synchronize and optimize activities, interventions
and messages.
Kenya’s TB advocacy strategy reached its final
stage in late 2007 and will soon be converted
to action. Future activities include identifying
organizations to implement the communication
strategy, developing campaigns and messages,
and building capacity to carry out community-level
interventions and other activities recommended by
the strategy.
ACSM for Tuberculosis Control: A Handbook for Country Programmes 35
Chapter 9: The objectives can also assess the effectiveness of each
Monitoring and evaluating
partner in disseminating materials or carrying out other
assigned tasks. The specifics of the intended ACSM
activities will determine the elements and objectives to be
ACSM activities included in the process evaluation.
In this chapter, the reader will learn about methods for Examples of questions that can be used to monitor
monitoring and evaluating ACSM activities. progress towards objectives are listed on the next page.
For monitoring, the reader will learn about:
1) conducting short-term and long-term monitoring and
tracking;
2) recognizing problems via feedback from the field; and
3) making mid-course corrections based on feedback.
For evaluation, the reader will learn about:
1) types of evaluations;
2) setting evaluation goals; “Before ACSM
3) determining suggested indicators;
4) developing an evaluation plan; activities begin,
5) selecting monitoring and evaluation methodologies;
6) developing and pre-testing data-collection instruments; create monitoring
and
mechanisms to
SECTION 3: Implementation and evaluation
7) writing an evaluation report.
1. Monitoring
receive feedback
on the interventions
1.1 Conducting short-term and long-term
monitoring and tracking and identify any
Before ACSM activities begin, create monitoring
mechanisms to receive feedback on the interventions problems early.”
and identify any problems early. Although it is impossible
to anticipate every problem, a monitoring system will help
identify difficulties quickly so that they can be addressed.
Determine the roles of partners in solving problems.
“Process evaluation” is the day-to-day monitoring of
ACSM activities and operations. Determine the objectives
of a process evaluation prior to establishing the monitoring
mechanisms.
The objectives should focus on:
• whether ACSM activities are on track,
• how close they are to meeting the projected timeline
and budget, and
• whether staff members understand and perform their
roles correctly.
 36 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes
Once objectives have been determined, select monitoring
How many people participated in activities? and tracking mechanisms. Some suggested sources of
information for tracking the various components of ACSM
activities include:
How many responses were received? How do they compare to those received in the months leading up • inventory of materials;
to the activity? What were the responses? • distribution list;
• activity reports;
• public diaries;
• television and radio logs;
How did the programme respond to enquiries? Was appropriate action taken in each case?
• media-clipping services;
• staff surveys or focus groups;
• partner feedback;
How many materials were sent out or otherwise disseminated? • timeline and budget assessments;
• news and information searches;
• legislative tracking systems; and
• attitude or household surveys.
How many materials were given to each of the partners? How many materials were disseminated by
these partners?
It is not enough to collect this monitoring data only once.
Planners need to review, analyse and discuss it regularly
– monthly, bimonthly or quarterly – depending on the
particular circumstances of the organization(s) involved. For
Were staff and partners adequately trained to carry out their roles effectively? Did they perform their some types of information, such as data from household
roles correctly?
surveys, it may make sense to collect information less
SECTION 3: Implementation and evaluation
frequently – either every six months or annually.
Planners should also decide whether to conduct internal
Are there any currently pending events, legislation or policies that might affect the programme or ACSM
programme team reviews or joint reviews with community
activities?
groups and/or other partners.
How many messages were sent to law-makers or other decision-makers? How many letters were
In addition to identifying areas that need attention or
written? How many meetings were held? How many articles were published in newspapers, magazines or
adjustment, monitoring also identifies successes. Celebrate
other publications?
successes with those involved. Each success, however
small, contributes to a growing sense of confidence and
accomplishment and motivates partners and other ACSM
participants to continue their efforts. Successes also
highlight areas in which capacity is being strengthened.
How many news stories appeared as a result of public relations efforts?
1.2 Recognizing problems via feedback from
the field
Have political conditions changed since the initiative was planned? Responding to relevant information in real time allows a
programme to improve immediately, rather than realizing in
retrospect what it should have done.
The following strategies for effectively using feedback from
Were all activities carried out on budget and according to the expected timeline? If not, why? the field can be implemented:
• Involve key decision-makers, stakeholders and TB
advocates in helping to analyse and use feedback;
How were the activities managed? Were workplans followed? How well did staff perform their duties? • Use process evaluation to uncover problems
Were relations among partners successful? Were donors kept apprised of activities? Were logistics well or opportunities for the ACSM intervention during
managed? Were other resources well managed? implementation;
• Conduct preliminary evaluations to identify potential
improvements and highlight and share successes before
the completion of ACSM activities; and
Have the knowledge, attitudes, awareness or opinions regarding TB changed in the intended group? • Use summative research to make future ACSM
Where can these changes be observed or obtained?
37
programme decisions part of a process rather than just an
end point.
1.3 Making mid-course corrections based on
feedback
The ACSM planning and implementation process is circular.
Feedback from the field might indicate programme areas or
ACSM interventions that should be changed, expanded or
phased out.
Consider also what might be added. For example, should
new developments in TB treatment be addressed? Has
anything changed about the intended population, the
community or the TB control programme that necessitates
creating new goals and objectives?
Consider the feedback questions below when deciding
whether mid-course corrections are necessary.
• Have goals and objectives shifted as activities have
been conducted? If so, revise the original goals and
objectives to meet the new situation.
• Are particular objectives not being met by programme
or ACSM interventions? Why? What barriers are being
SECTION 3: Implementation and evaluation
encountered? How can the barriers be overcome?
• Has a strategy or approach met all its objectives or
does it seem not to be working at all? Consider ending
that tactic.
• Is there any new intervention or treatment information
that should be incorporated into the messages or design?
• Which strategies or activities have not succeeded?
Review why they do not work and determine what can be
done to correct any problems.
Identifying successes can also lead to mid-course
corrections. If certain activities have been shown to be
successful, planners might consider focusing on them and
discontinuing those that are less successful. Following are
some questions to help assess the value of successes.
• Which objectives have been met? What activities have
succeeded?
• Should successful activities be continued and
strengthened because they appear to work well or
should they be considered successful and subsequently
discontinued?
• Can successful activities be expanded to apply to other
groups or situations?
• What were the costs (including staff time) of different
aspects of the ACSM intervention?
• Do some activities appear to work as well as others, but
cost less?
• Do programme funders need evidence of ACSM
success to continue funding activities?
• Have the results of the activities been shared with the
 38 ACSM for Tuberculosis Control: A Handbook for Country Programmes
TB programme leadership and partners? With funders,
advocates or other stakeholders?
• Do the assessment results show a need for new
activities that would require establishing partnerships with
additional organizations?
Consider the above questions with regard to problems
encountered and successes achieved, then identify new
strategies, target different intended groups and revise
ACSM activities and products to accommodate new
approaches, new tasks and new timelines.
2. Evaluation
At some point all programmes need to ask the question,
“How effective were the ACSM strategies?” This is the time
to reflect on what has been achieved, what has worked
and what has not, and to make recommendations to
improve future efforts. A summative evaluation will not only
help to answer these questions, but also to demonstrate to
funders and partners the effectiveness of activities.
2.1 Types of evaluations
There are two types of summative evaluation: outcome
evaluation and impact evaluation.
SECTION 3: Implementation and evaluation
An outcome evaluation measures how well the ACSM
intervention has met its objectives and what should be
changed to improve future ACSM activities.
Follow the steps below to conduct an outcome
evaluation:
• determine what information the evaluation must provide;
• define the data to collect;
• decide on data collection methods;
• develop and pre-test data collection instruments;
• collect data;
• process data;
• analyse data to answer the evaluation questions;
• write an evaluation report; and
• disseminate the evaluation report.
When conducting an outcome evaluation the limitations
and constraints can include:
• limited funds;
• limited staff time or expertise;
• length of time allotted to the ACSM intervention and its
evaluation;
• restrictions on hiring consultants or contractors to
conduct the evaluation;
• policies that limit the programme’s ability to collect
information from the public;
• difficulty in defining or establishing consensus on ACSM
objectives;
• difficulty in isolating the effects of ACSM intervention
from other influences; and
• a perception by funders or others involved in the
programme that evaluations are not valuable.
These constraints can often be overcome. However, if a
programme faces several constraints, it might be advisable
to conduct a small-scale evaluation. This would be more
valuable than a poorly conducted large-scale evaluation.
Impact evaluation connects behaviour change to
health or social outcomes. An impact evaluation answers
the question: “Did the people who adopted new actions
or behaviour experience improved health and well-
being related to their TB status?” Impact evaluations are
not often used by planners of ACSM activities – mostly
because of the high costs usually involved in carrying them
out successfully. However, evaluators can select a few
programmatic objectives to measure, such as changes
in the rates of treatment completion or increases in case
detection.
2.2 Setting evaluation goals
To set evaluation goals, first determine who wants to learn
from the evaluation. This will be primarily the stakeholders
involved in ACSM activities or those with a direct interest
in the programme. Other interested parties – such as
the broader community, the various levels of the health
system, people from the municipal/district/regional/national
governments and donors – should also be invited to
suggest evaluation goals or participate in other ways. There
may also be people and organizations that are interested
in learning from the evaluation although they may not have
been directly involved in the process. Potential future
partners might also be invited to participate, to provide an
external perspective and to further their understanding of
the approach used and its results.
List individuals and organizations interested in participating
in the evaluation. Remember that they need not be
physically present; they can contribute questions or
thoughts on aspects that they are interested in learning
about. (Do not promise to incorporate all their questions
into the evaluation, as time and resources will be limited.
Try to address concerns not included in another way.)
After deciding on who should be involved, determine what
they want to learn from the evaluation. This will often link to
their roles in the effort, such as a donor wanting to know
whether the money that was invested was well spent, or a
policy-maker wanting to know whether a media campaign
improved TB diagnosis rates in the community.
ACSM for Tuberculosis Control: A Handbook for Country Programmes
It is important to determine which aspects of the outcome
evaluation plan best fit with the programme’s priorities. It is
rare for an ACSM programme to have adequate resources
to evaluate all its activities. Some specific questions to
ask in setting up objectives for an evaluation are outlined
below:
• What are the ACSM objectives?
What should the members of the intended group think,
feel or do as a result of the ACSM activities, in contrast to
what they thought, felt or did before?
• How is change expected to occur?
Will it be slow or rapid? What measurable intermediate
outcomes – steps toward the desired behaviour – are likely
to take place before the behaviour change can occur?
• How long will the intervention last?
What kind of changes in attitude, awareness, behaviour or
policy, for example, can be expected in the time period?
Sometimes, when the outcomes are measured, activities
or interventions will not have been in place long enough for
objectives to have been met.
• Which outcome evaluation methods can capture
the scope of the change that is likely to have
occurred?
When sample sizes are small (usually due to funding
constraints), the evaluation is said to lack statistical power
and only fairly large changes will be statistically significant.
Programmes should consult a statistician to make sure that
the size of the sample is adequate to measure the amount
of change that they expect to see.
2.3 Determining suggested indicators
Changes in the evaluation indicators, or key outcomes
to be measured, indicate whether objectives have
been achieved. Select the indicators that identify where
ACSM initiatives have been the most successful or
where additional work is needed. Link indicators to the
objectives set during the planning process. All indicators
must be measurable.
Individual-level indicators measure:
• knowledge;
• attitudes;
• beliefs;
• behaviour;
• stage of willingness to change; and
• demographics.
Community-level indicators use data from organizations,
public agencies or other groups to show trends occurring
on a larger scale. A key method of tracking community-
based indicators is to observe people’s behaviour or
relevant factors in the community. Community-based
indicators measure changes in:
39
• policy and regulation;
• information accessibility;
• behaviour;
• social norms, including stigma; and
• presence or mobilization of social networks.
Community-based indicators are usually less expensive
and time-consuming to track because data are collected
from a few sources rather than from many individuals.
However, the information gathered might not be as relevant
to TB programme objectives.
2.4 Developing an evaluation plan
At a minimum, an evaluation plan should answer several
key questions, as outlined below:
a) What are the project’s objectives and expected
outcomes? What questions should be asked?
• What elements of the project worked?
• What elements did not work?
• What were some successes?
• What were some failures?
• What still remains to be done?
• What is the vision for the future?
SECTION 3: Implementation and evaluation
• How has capacity been strengthened during the
intervention?
• Which results obtained during the intervention are likely
to be sustained or improved upon?
b) What information is needed to answer the
above questions and how will the information be
collected?
List the instruments and methods that will be used to
collect the information, such as:
• repeated surveys (baseline and follow-up);
• stories (peak moments, peak achievements);
• drawings (e.g., of project history);
• role plays to present important milestones or events;
• in-depth interviews with project participants and
observers;
• group discussions;
• picture-card pile sorts (sort interventions that worked or
did not);
• rankings (rank initiatives or interventions, from those that
worked best to least); and
• review of the project proposal, reports and documents.
c) Who will collect the information?
It is more cost-effective to use existing human resources
and platforms, if possible, to collect information. Ideally,
staff should not collect information that directly measures
the success or failure of their own efforts.
 40 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 41

d) What resources/materials will be needed?
List who needs support in collecting the information from
different sources and what support they need.
e) When will this information be collected?
Create a timeline for data collection.
2.5 Selecting the monitoring and evaluation
methods
For the broadest view of areas where the ACSM programme
has been most effective and those where improvement
may be needed, use quantitative and qualitative research
methods to collect evaluation data.
• Qualitative methods may include in-depth interviews,
focus groups or anecdotal feedback mechanisms such
as diaries and observational studies (watching people in a
natural setting without their awareness and observing their
behaviour).
• Quantitative methods may include sales data, service
statistics or surveys.
Which data?
The data collected should be directly related to the
evaluation questions. For example, if members of the
intended group need to know more about a topic before
behaviour change can take place, ask knowledge-related
questions in the evaluation.
From whom?
Evaluators should decide how many members of each
group are required in the evaluation to measure change.
There should be adequate resources to collect information
from the number of people required. Different data-
collection instruments and methods for different groups
may be necessary.
How?
Assess available resources before deciding how to collect
data. Are skilled interviewers accessible or can staff
members be trained? Will self-reports from participants
be used? If so, do any confidentiality issues need to be
addressed?
2.7 Writing an evaluation report
To prepare an evaluation report, have staff with appropriate
expertise analyse the outcome evaluation data and work
closely with the evaluators to interpret the data and develop
recommendations.
An evaluation report should:
• present the lessons learnt in a clear format that can be
easily digested by others who may be planning future
ACSM activities;
• demonstrate accountability to employers, partners and
funding agencies;
• provide evidence of the effectiveness of the ACSM
interventions and activities; and
• create a formal record to serve as an institutional
memory of what has been tried, which partners had
strong skills or experience in specific areas, what
problems were encountered and what successes were
achieved.

Select a method that allows the programme to best answer Consider also whether participants will be comfortable with
evaluation questions based on access to the intended the data collection-methods.

SECTION 3: Implementation and evaluation

SECTION 3: Implementation and evaluation

population and resources. Consider using participatory • Will they be willing and able to fill out forms?
methods that make people living with, and affected by, • Will they share personal information with interviewers?
TB part of the research process. Participatory research • Will the interviews and responses need to be
allows those affected by TB to help in defining the issues
and working out solutions rather than being just sources
translated?
“Select a method that
from which information is extracted. Participatory methods
provide ample opportunity for personal exchange so allow
Methods of gathering information and interpreting results
may vary depending on the culture and experience of the allows the programme
adequate time for people to go at their own pace. respondents. For example, some people may not speak
out in a group, such as a focus group; some may be to best answer
The more complex the evaluation design is, the more expert
assistance is needed to conduct the evaluation and interpret
unwilling to provide answers they think will displease the
interviewer; others may be reluctant to provide information evaluation questions
the results. An evaluation expert can be hired or assigned
to help write questions that produce objective results. (It
to a person from a different culture or social status over
the telephone; and many may lack familiarity with printed based on access to the
is easy to draw up questions that inadvertently produce
overly positive results.) If an evaluator is not on staff, seek
questionnaires or have a limited ability to read the language
on the questionnaire. intended population and
help to decide what type of evaluation will best serve the
effort. Sources of expertise include university faculty and In addition, the evaluator’s social status (if it is different from resources. Consider
graduate students (for data collection and analysis), local
businesses (for staff and computer time), health agencies,
that of the respondent) or demeanour could inadvertently
affect the objectivity of the evaluation. When possible, using participatory
consultants and organizations with evaluation expertise. try to use evaluators who will make the respondents feel
comfortable. methods that make
2.6 Developing and pre-testing data collection people living with, and
instruments
Most outcome evaluation methods involve collecting data affected by, TB part of
on participants through observation, questionnaires or
participatory methods. the research process.”
To develop data collection instruments– or to select and
adapt existing ones – ask the questions below.
 42 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Monitoring TB programme effectiveness in Ukraine
In Ukraine, the NTP collaborated with the World
Health Organization, regional and national
health authorities, the World Bank and Royal
Netherlands Tuberculosis Association (KNCV)
to develop a standardized TB management
information system (TBeMIS) based on the
WHO-recommended approach. Registration and
case-management of all TB cases in pilot sites
are tracked electronically using the TBeMIS. This
monitoring system is being used successfully
to identify programme interventions that need
improvement, as described below.
Data collected by the TBeMIS were used as
part of the evaluation of a model that involved
the Ukrainian Red Cross Society (URCS) Visiting
SECTION 3: Implementation and evaluation
Nurses Service in Kyiv city and Donetska
oblast (Mariupol’, Yenakievo, and Horlivka) in
implementing DOTS for people with TB during
the continuation (or maintenance) phase. The
main goals of this study were to determine the
needs of TB patients during ambulatory care
and to develop effective collaboration methods
CASE STUDY no. 7
between local NGOs and medical facilities involved
in TB care and support.
The selected indicators measured patient
satisfaction with care and overall programme
progress, as well as the number of patients who
were supported and cured by the Red Cross
visiting nurses. The primary indicator to evaluate
the effectiveness of this care model was the
comparison of the treatment default rates between
pilot cities and other regions of Donetska oblast.
In the three pilot cities where this programme has
been active for more than one and a half years,
preliminary results suggest that the likelihood of
treatment default is substantially lower in these
cities than in the rest of the oblast. The data are
encouraging, although they are based on rather
small sample sizes.
ACSM for Tuberculosis Control: A Handbook for Country Programmes
Chapter 10:
Documenting results and
providing feedback
By the end of Chapter 10, the reader will understand how
to:
1) extract lessons learnt from ACSM activities;
2) identify people and organizations that should be aware
of these findings; and
3) disseminate lessons learnt and other findings.
Knowledge and expertise related to ACSM activities can
be disseminated to others involved in TB control in various
ways. The wealth of experience and knowledge created
and generated within affected countries and communities
often remains known to only a few practitioners.
By documenting and sharing ACSM lessons, NTPs and
partners can review experiences and provide strategic
input for future activities. ACSM challenges, activities
and lessons are similar across regions. Sharing ideas
between countries therefore enables “cross pollination” of
experiences and prevents “reinventing the wheel”. Sharing
results may also prompt partners to reciprocate with
similar experiences, lessons they have learnt, new ideas or
potential resources.
1. Extract “lessons learnt” from ACSM
activities
It is difficult to decide which experiences are worth
sharing with others. Communities and organizations often
undervalue their rich experience, believing that what they
have learnt may be obvious or uninteresting. Consequently,
information about many effective community-based activities
never spreads beyond the local area. Some people believe
that, if they do not achieve everything planned, their efforts
have failed and are not worth sharing. Nothing could be
further from the truth!
First, not all ACSM interventions achieve positive results.
Disappointing results may occur for many reasons.
Sometimes events or poor decisions beyond the control of
planners and implementers may be the cause. It is valuable
to learn about successes and failures in TB control.
”Failures” sometimes provide the most useful information
for future planning.
ACSM planners should always review what happened
and why. The following questions are to guide the review
process in understanding lessons.
43
• To what extent has the project achieved its objectives?
• How much did the activity/activities cost?
• What worked? What did not work?
• What should have been done differently? What will be
done differently in the future?
• What assumptions were made that were not true when
evaluated?
• Did areas/communities/people not reached by the
ACSM interventions fare better or worse than the target
populations? Why?
• What questions remain to be answered?
• What new questions have emerged?
• What would an outsider want to know about this
activity?
• What is the value of the ACSM activities in comparison
to other NTP programme components?
A helpful tool that can be used to extract “lessons learnt” is
an after-action review (AAR). The AAR is a knowledge-
sharing tool that has been increasingly used by the United
States Agency for International Development (USAID) and
its partner community to better understand important
events, activities and/or programmes. Overall, an AAR is a
discussion of an event (or activity), led by people who are
SECTION 3: Implementation and evaluation
closest to the activity. It focuses on performance standards
and enables planners to discover for themselves what
happened, why it happened, and how to sustain strengths
and improve on weaknesses.
Feedback compares the actual output of a process with the
intended outcome. By focusing on the desired outcome
and by describing specific observations, planners can
identify strengths and weaknesses and together decide
how to improve performance. Moreover, this shared
learning process promotes bonding, collegiality and group
cohesion.
Because AAR participants actively discover what has
happened and why, they can learn and remember more
than they would from a critique or more formal evaluation.
A critique only gives one viewpoint and frequently provides
little opportunity for participants to discuss what has
happened. The climate of a critique – focusing on what
is wrong – often prevents candid discussion and stifles
opportunities for learning and team building.
All AARs follow the same general format, involve the
exchange of ideas and observations, and focus on
improving training proficiency. AAR organizers decide
whether the review will be formal or informal.
• Formal AARs require more resources and involve
more detailed planning, coordination, logistical support,
supplies and time for facilitation and report preparation. A
facilitator guides the review discussion and, with the help of
 44 ACSM for Tuberculosis Control: A Handbook for Country Programmes
a note-taker, records comments on a flip chart. Following
the AAR session itself, a formal report is prepared. Later,
recommendations and actionable items are brought to the
attention of whoever is managing the effort.
• Informal AARs are usually conducted on-site
immediately following an event, activity or programme.
Frequently, an informal AAR is carried out by those who
have conducted the activity. If necessary, the discussion
leader or facilitator can either be identified beforehand or
chosen from within the implementing group itself.
Again the guiding questions are used to generate
discussion. Team or project leaders may use informal
AARs as on-the-spot coaching tools while reviewing overall
group or individual performance.
For example, the team could:
• quickly evaluate performance against a desired standard
or established performance objective;
• identify strengths and weaknesses; and
• decide how to improve performance.
In addition, informal AARs provide instant feedback: ideas
SECTION 3: Implementation and evaluation
and solutions can be immediately put to use and the team
can learn from them for a future or similar application.
Providing direct feedback, “just in time”, is a key strength
of the informal AAR.
The date and time of the AAR should be identified as part
of the planning schedule for the event. The AAR should
be considered as an integral part of the entire planning
process. For more information, USAID has published
a guide on how to conduct an AAR, After-action review.
Technical guidance4.
4 After-action review, Technical Guidance can be downloaded from the Internet at http://pdf.usaid.gov/pdf_docs/PNADF360.pdf
2. Identify people and organizations that
should be aware of the findings
Many people will be interested in what has been learnt
from the ACSM activities. Consult the lists of stakeholders
or potential partners that have already been compiled.
These organizations may include, but are not limited to,
the following:
• other NTPs;
• NTP project staff;
• community-based organizations;
• faith-based organizations;
• international and national-level NGOs;
• health professional groups, medical centres, clinic
administrators;
• law and policy-makers;
• members of television, radio and printed media;
• other public health programme administrators;
• evaluators, epidemiologists and researchers;
• funding agencies;
• partner organizations; and
• the public.
More than likely, many of these groups will want the
information presented in different ways. For each type of
audience, consider the questions below.
• How much information will they want – a complete written
report, an executive summary or selected sections of an
evaluation?
• How will the information be used – to refine a programme
or policy, to evaluate the programme’s performance, to
inform others, to support advocacy efforts or to plan future
ACSM initiatives?
• In what format will they want the information – concise,
with hard-hitting findings and recommendations; general,
with an overview written for the public at a low reading-
level; scientific, including a methodology section, a detailed
discussion and references; visual, including more charts
and graphics than words; or case studies, including other
story-telling methods?
• What elements should be included – general intervention
results/findings, evaluation methods, a chronology of
activities, history of the NTP, a theoretical basis for programme
and ACSM activities; implications; recommendations;
barriers or reasons for unmet objectives?
ACSM for Tuberculosis Control: A Handbook for Country Programmes 45
3. Disseminate lessons learnt and other
findings
How information is disseminated will depend on who is
getting what type of information.
With new information technologies – including the World
Wide Web’s programme web sites, blogs, message boards
and list servers), it is easier to share information within a
community, district and country, as well as more broadly
with peers all over the world. A few examples of this are
the Communication Initiative’s web site (www.comminit.
“Written reports, articles
com) and e-magazines such as Health Communication
Exchange (http://www.healthcomms.org) and HDNet
and other ACSM
(http://www.hdnet.org). updates can be shared
Written reports, articles and other ACSM updates can be
shared through community newsletters, newspaper or
through community
journal articles and presentations at community or national-
level meetings. Other creative ways to share results and
newsletters, newspaper
encourage more dialogue and learning include a “gallery
walk” where people view results presented as pictures.
or journal articles
Small groups stop at each picture posted on the wall and
describe what they see. This way a facilitator can explain
and presentations at
the results in more detail and answer questions. A blank community or national-
SECTION 3: Implementation and evaluation
sheet placed next to each picture can be used to record
comments and questions. level meetings.”
Another example is an information-sharing forum,
where a facilitator discusses the results with a small group
of five or six people and asks open-ended questions to
learn about their reactions to the results. The group is
encouraged to ask questions and offer opinions.
Role plays can present results in entertaining ways.
For example, someone can portray a reporter giving a
newscast – interviewing other members of the planning or
implementation team then interviewing the “audience” for
its reactions.
Participants’ observations should be incorporated into the
NTP’s analysis of the ACSM activity.
It is also critical to share results with social/community
mobilizers who work with people affected by TB. This is a
way to get feedback on results and keep them engaged
in the process – from planning activities to sharing them.
Such activities with partners reinforce the idea of collective
work, a defining factor of true partnership.
 46 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Sharing lessons learnt in Ukraine
While implementing Ukraine’s national TB plan,
several developments have emerged that
illustrate the change in the country:
• new national and oblast legislation and policy
documents supporting modern TB control
standards have been created;
• a central coordinating unit for the NTP has
been established; and
• an increased commitment and interest from
officials involved local organizations, such as the
Ukrainian Red Cross Society, and increased the
demand for DOTS training from other oblasts.
Working at the oblast level to build support and
SECTION 3: Implementation and evaluation
demonstrate the effectiveness of a DOTS-based
strategy was instrumental in overcoming national-
level resistance to changing TB control practices.
A few key best practices and lessons learnt
include the following.
• Working to change policy and political will is an
extremely time-consuming and labour-intensive
process that should be factored into project
planning.
• The close coordination of all donors and
partners has been instrumental in increasing
political commitment by crafting a consistent
message on TB and using different players
to exert pressure on officials or mobilize
stakeholders for advocacy.
• Starting with efforts at the oblast and rayon
levels to circumvent strong national opposition
to DOTS has created useful allies and supported
the changes seen at the national level.
CASE STUDY no. 8
• Using a few high-level consultants at key points
in the project has had two very positive effects: a)
it has increased staff knowledge and confidence,
and b) it has strengthened recommendations to
national and oblast officials.
• Targeted, well-planned exchange visits to other
countries and other oblasts – using the “seeing
is believing” strategy – has convinced many
sceptics not only that DOTS can work in the
European region, but also that it is a particularly
useful strategy for supporting changes in practice
throughout the region.
• Working through existing structures (such as
the Ukrainian Red Cross Society and medical
institutions) to institutionalize DOTS, promotes the
sustainability of project activities.
The best practices and lessons learnt are being
shared widely in different ways. Presentations at
meetings and symposia (e.g. board meetings of
the city health administration, TB and family health
departments of the national medical university,
and the National Congress of Family Doctors)
have reached Ukrainian stakeholders. The annual
meetings of the Global Health Council and the
International Union against Tuberculosis and
Lung Disease have shared Ukraine’s results with
international players.
Collaborative meetings of the WHO Regional Office
for Europe and the European Regional Meeting
of the International Union Against Tuberculosis
and Lung Disease have informed key European
stakeholders. In these ways, ACSM activities
in Ukraine are providing strategic direction to
efforts in support of national TB programme
implementation worldwide.
ACSM for Tuberculosis Control: A Handbook for Country Programmes 47
References
Advocates for Youth. Advocating for Adolescent Reproductive Health in Sub-Saharan Africa. Washington, DC, 1998.
AMC Cancer Research Center. Beyond the Brochure: Alternative Approaches to Effective Health Communication – A Guidebook. Denver,
CO, 1994.
CARE International. Advocacy Tools and Guidelines: Promoting Policy Change. Atlanta, GA, 2001.
Family Health International. Strategic Behavioral Communication for HIV and AIDS: A Framework. Research Triangle Park, NC, September
2005.
Government of India, Ministry of Health and Family Welfare, Directorate General of Health Services, Central TB Division. A Health
Communication Strategy for RNTCP. November 2005.
Health Communication Partnership. Health Communication Insights: The Role of Health Communication in Viet Nam’s Fight Against
Tuberculosis. Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs, Baltimore, MD, 2004.
Health Communication Partnership. Health Communication Insights: The Role of Health Communication in Achieving Global TB Control
Goals – Lessons from Peru, Viet Nam and Beyond. Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs,
Baltimore, MD, 2004.
Health Communication Partnership. How to Mobilize Communities for Health and Social Change. Johns Hopkins Bloomberg School of
Public Health/Center for Communication Programs, Baltimore, MD.
International Union Against Tuberculosis and Lung Disease. Best Practice for the Care of Patients with Tuberculosis: A Guide for Low-Income
Countries. Paris, 2007.
Kline N. Hands-On Social Marketing. A Step-by-Step Guide. Sage Publications, Thousand Oaks, California: 1999.
Open Society Institute of the Panos Institute. Civil Society Perspectives on TB/HIV Policy. New York, NY, 2006.
Panos Institute. Time for Action on TB Communication: A briefing for policy-makers, programmers and health communicators on
contemporary communication opportunities and challenges. New York, NY, 2005.
Panos Institute. What the papers aren’t saying. How can we enhance media coverage of TB? New York, NY, 2007.
Pan American Health Organization. Planning Social Mobilization and Communication for Dengue Fever Prevention and Control: A Step-by-
Step Guide. Washington, DC, 2004.
U.S. Agency for International Development, Bureau for Africa, Office of Sustainable Development, Support for Analysis and Research in
Africa (SARA). An Introduction to Advocacy: Training Guide. Washington, DC, 1997.
U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Making Health Communication
Programs Work. Bethesda, MD, 2001.
U.S. Agency for International Development, Bureau for Africa, Office of Sustainable Development. Tuberculosis and Gender: A pilot study in
Tanzania. Washington, DC, 2004.
WHO, Global Polio Eradication Initiative. Advocacy – A Practical Guide with Polio Eradication as a Case Study. Geneva, World Health
Organization, 1999.
WHO, Global Tuberculosis Programme. TB Advocacy: A Practical Guide. Geneva, World Health Organization, 1999.
WHO, Global Tuberculosis Programme. Guidelines for Social Mobilization – Planning World TB Day. Geneva, World Health Organization,
2000.
WHO, Stop TB Partnership. Guidelines for Social Mobilization – A Human Rights Approach to Tuberculosis. Geneva, World Health
Organization, 2001 (WHO/CDS/STB/2001.9).
WHO, Stop TB Initiative. TB Advocacy Report, 2003. Geneva, World Health Organization, 2003 (WHO/CDS/TB/2003.321).
REFERENCES
WHO, Stop TB Partnership. Advocacy, Communication and Social Mobilization to Fight TB – a 10-Year Framework for Action (2006–2007).
Geneva, World Health Organization, 2006.
WHO, Stop TB Partnership. Advocacy, Communication and Social Mobilization for TB Control: A guide to developing KAP surveys. Geneva,
World Health Organization, 2007 (Draft).
 48 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Annex A
Selected strategic assessment and planning tools
The description of tools in Annex A is an excerpt from Advocacy, Communication and Social
Mobilization to Fight TB – a 10-Year Framework for Action (2006–2007)5.
The P Process
The P Process is a framework that enables the user to develop a strategic health communication
programme. The P Process lays out a logical framework for a communication intervention—analysis,
strategic design, development and testing, implementation and monitoring, and evaluation and
replanning. Community participation and capacity-building are embedded in each step of the
process. The P Process has been applied to a wide range of health issues.
At every stage of the P Process, there are basic principles for strategic communication
programmes.
• Strategic thinking: Identify communication – not as posters and brochures or even television
spots and radio dramas, but as a continuous, direct, and major influence on behaviour and policy.
Mobilize and deploy the power of communication at all levels to promote and support good health
practices.
• Leadership support: Build support among national and local leaders continuously, from the
initial assessment to the sharing of evaluation results. Enable political, religious, and community
leaders to share credit for programme accomplishments.
• Audience participation: Encourage your audience to be actively involved at every stage –
assessing their needs, planning the strategy, carrying out local activities, assisting in monitoring
and evaluation and engaging in advocacy. Develop key messages around the needs of, and the
benefits for, the audience.
• Interdisciplinary approach: Work with people from different disciplines and backgrounds,
including nurses, marketing professionals, social scientists, auxiliary health personnel, physicians,
pharmacists, epidemiologists, anthropologists, and communication specialists throughout the life
of the programme to secure the diverse skills and technical expertise needed.
• Coordination with service providers: Design communication programmes to identify and
reinforce service facilities and to promote access and quality. Encourage and train health-care
providers to use or refer to appropriate materials and messages in dealing with clients. Encourage
communication experts to highlight the role of good providers.
• Public–private partnerships: Build partnerships among government agencies, NGOs, and
the commercial sector to reinforce communication programmes and to share materials, messages,
training, and other resources. Learn from one another.
• Multiple channels: Establish a lead agency and a lead channel to carry the message and
reinforce it with other appropriate media – mass, community and interpersonal. Use media that
reach the intended audiences best to achieve the most cost-effective programme.
ANNEX A
5 WHO. Stop TB Partnership. Advocacy, Communication and Social Mobilization to Fight TB – a 10-Year Framework for Action
(2006–2007). Geneva, World Health Organization, 2006.
ACSM for Tuberculosis Control: A Handbook for Country Programmes 49
• Enter-educate approaches: Never underestimate the power of entertainment to reach and
persuade audiences, especially young people and those who are not health professionals. Develop
and adapt entertaining materials for mass media and community distribution.
• Training and capacity-building: At every step, train individuals and build institutional
capabilities to carry out effective programmes. Use educational sessions and on-the-job training
to create a critical mass of communication experts.
• Monitoring and evaluation: Plan for evaluation from the start to measure changes in the
intended audiences and to know whether objectives are achieved. Monitor project outputs regularly
and make necessary adjustments. Share findings widely to improve future programmes.
• Continuity and sustainability: Plan for continuity from the start, with activities that can become
sustainable over time. Expand programmes, services, activities, and coalitions as appropriate to
build a larger base for advocacy and community support.
Over 15 years of experience, the P Process has been revised to better reflect the needs of the
field and improvements in knowledge. The revised P Process adds the following new elements to
the original formulation:
• emphasis on national communication strategies and positioning of products, practices, and
services;
• more effective message development using the Seven Cs of Communication (command
attention, cater to the heart and head, clarify the message, communicate a benefit, create trust,
convey a consistent message, call for action);
• management of results;
• building a positive organizational climate;
• theory-based impact evaluation with multiple data sources; and
• early planning for resource generation and sustainability.
Communication for Behavioural Impact (COMBI)
Since 2001, the WHO Social Mobilization and Training Team (SMT) has been applying an approach
known as COMBI (Communication for Behavioural Impact) in the design and implementation of
social mobilization and communication plans for the adoption of healthy behaviours. COMBI is
social mobilization directed at the task of mobilizing all societal and personal influences on an
individual and family to prompt individual and family action. It is a process that strategically blends
a variety of communication interventions intended to engage individuals and groups in considering
recommended healthy behaviours and to encourage the adoption and maintenance of those
behaviours.
ANNEX A
 50 ACSM for Tuberculosis Control: A Handbook for Country Programmes
COMBI incorporates the many lessons of the past 50 years of health education and communication
in a behaviour-focused, people-centred strategy. COMBI also draws substantially from the
experience of the private sector in consumer communication. COMBI is an integrated programme
made up of five components.
• Public relations/advocacy/administrative mobilization: for putting the particular healthy
behaviour on the business sector and administrative/programme management agenda via the
mass media – news coverage, talk shows, soap operas, celebrity spokespersons, discussion
programmes; meetings/discussions with various categories of government and community
leadership, service providers, administrators, business managers; official memoranda; partnership
meetings.
• Community mobilization: including use of participatory research, group meetings, partnership
sessions, school activities, traditional media, music, song and dance, road shows, community
drama, leaflets, posters, pamphlets, videos, home visits.
• Sustained appropriate advertising and promotion: in m-rip fashion – massive, repetitive,
intense, persistent – via radio, television, newspapers and other available media, engaging people
in reviewing the merits of the recommended behaviour vis-à-vis “cost” of carrying it out.
• Personal selling/interpersonal communication/counselling: involving volunteers, school
children, social development workers and other field staff at the community level in homes and
particularly at service points, with appropriate informational literature and additional incentives, and
allowing for careful listening to people’s concerns and addressing them.
• Point-of-service promotion: emphasizing easily accessible and readily available TB diagnosis
and treatment.
The COMBI approach assumes a series of steps in how people change their behaviour in response
to a message. First, people hear about TB, its cause and its solution (presenting for a sputum test
and taking the drug treatment); then, they become informed about the disease, its cause and
solution.
Later, they become convinced that the solution is worth while adopting and decide to do something
about their conviction, and take action on the new behaviour. They then await reconfirmation that
their action was a good one and, if all is well, they maintain the behaviour (returning for another
sputum test if the same TB-like symptoms appear again).
The COMBI approach has already been piloted in several countries, including India and Kenya,
and a review has been commissioned by the Stop TB Partnership Secretariat to assess the impact
and lessons learnt from this experience. A very detailed explanation of the COMBI process, and
the thinking it rests on, has been produced by the Stop TB Partnership.
Communication for Social Change (CFSC) Approach
CFSC is a process of public and private dialogue through which people define who they are, what
they need and how to get what they need in order to improve their own lives. It utilizes dialogue that
leads to collective problem identification, decision-making and community-based implementation
of solutions to development issues. It is communication that supports decision-making by those
most affected by the decisions being made. CFSC’s focus is on the dialogue process through
which people are able to remove obstacles and build structures/methods to help them achieve
the goals they have outlined and defined. Rather than focusing on persuasion and information
ANNEX A
dissemination, CFSC promotes dialogue, debate and negotiation from within communities.
ACSM for Tuberculosis Control: A Handbook for Country Programmes 51
CFSC practitioners use a “bottom-up” approach by placing ownership, access, and control
of communication directly in the hands of affected communities. This shifts control of media,
messages, tools and content of communication from the powerful to the traditionally powerless.
Ultimately, using such skills, previously powerless communities can become “self-renewing” – able
to manage their own communication processes for their own good.
Similar to other participatory communication approaches, the process of CFSC is often more
important than the products. CFSC does not attempt to anticipate which media, messages or
techniques are better. The participation of social actors, who are in turn communicators, takes place
within a process of collective growth that precedes the creation of messages and products such
as a radio programme, a video documentary or a pamphlet. Messages and their dissemination are
just additional elements of the communication process.
The driving forces of CFSC can be synthesized as described below.
• The societies in which TB has the greatest impact are changing rapidly. The way in which people
receive, interpret and act on information, the way in which they communicate with each other,
the way in which they make their voices heard within their own communities and nationally – all
these have undergone a profound transformation over the past decade or so. In most high-burden
countries, the media has undergone a revolution – formerly monolithic media structures (capable
of disseminating simple messages to much of the population) have given way to much more
fragmented media landscapes.
Radio, often the most important source of information for poor people, has been particularly
transformed, in both its structure and its character. People listen more to talk shows, phone-ins and
conversations; radio is arguably catalysing a renewal of the oral character and richness of many
developing country societies. Information and communication technologies, although extremely
restricted in their reach, are also contributing to a more horizontal, noisy, and discussion-oriented
communication environment. Such an environment makes the simple conveyance of messages
through mass media more difficult (because there are more channels and people have a greater
choice in what they pay attention to) but also provides important new opportunities for health
communication programmes. CFSC programmes have particularly sought to adapt communication
strategies to these new environments.
• During several decades the same models, messages, formats and techniques were utilized –
and still are today – in distinct cultural contexts. The communication process cannot ignore or deny
the specificity of each culture and language; rather, it should support them to acquire legitimacy
and thereby support “cultural renewal.” Cultural interaction, or the exchanges between languages
and cultures, is healthy when it happens within a framework of equity and respect, through critical
dialogue, debate of ideas and solidarity.
• Vertical models of communication for development take it for granted that poor communities in
developing nations lack “knowledge”. Access to information generated in industrialized countries
is sometimes seen as a “magic bullet”. CFSC is cautious of the linear model of transmission
of information from a central sender to an individual receiver, and promotes instead a cyclic
process of interaction focused on shared knowledge and collective action. CFSC strengthens
local knowledge and promotes exchanges in equal terms, learning through dialogue, in a process
of mutual growth. CFSC should be empowering, horizontal versus top-down, give a voice to
previously unheard members and be biased towards local content and ownership. In short, CFSC
is concerned with culture and tradition, respect towards local knowledge, and dialogue between
development specialists and communities. CFSC is about engaging people to want to change, to
define the change and required action, and to carry them out. The goal of CFSC is self-renewing
ANNEX A
societies.
 52 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 53

There are comparatively few examples of CFSC applied to TB control. An NGO in Bangladesh, The pathway is designed to help NTPs identify where TB drop-outs are occurring, and for each step of the
Building resources across communities (BRAC), is pioneering a new process called Participation, pathway it lists the most common barriers at the individual, group and systems levels. It outlines six steps
Interaction and Mobilization (the PIM Process). It is aimed at providing a comprehensive approach and identifies the behavioural barriers to people taking these steps at each stage.
that locates social empowerment as the critical engine of behavioural change and argues that social
empowerment means active community participation by civil societies in disease management, • First, to seek timely care.
providing help to formal health-service providers as well as community health agents. BRAC uses • Second, to go a DOTS facility.
Shastho shebikas – key health agents – who have emerged from the community.
• Third, to get an accurate diagnosis.
Through a process catalysed by these health agents, community members participate in creating • Fourth, to begin treatment.
awareness, mobilization, household level visits and stigma reduction through social interaction,
disabling stigma generation and creating a sense of a common goal. It does not replace any agency • Fifth, to persist in getting treatment.
or approach but utilizes the meaning of partnership. It is good, argues BRAC, for monitoring, social • Sixth, to complete treatment.
auditing and message delivery. Ultimately the approach is aimed at broadening ownership and
agency of TB disease management from a smaller group of health managers at various levels to Baseline studies need to be conducted to identify key barriers to completing ideal behaviours. Then,
include civil society as a whole, including various social groups like youths, household leaders, programmes need to weigh the relevance of different barriers in order to prioritize courses of action and the
women, clubs, religious groups, etc. focus of communication interventions.

CFSC has many similarities and complementarities to a community DOTS approach and is See an illustration of the pathway below.
particularly appropriate in tackling issues of stigma and community inclusion in DOTS. Any CFSC
approach does focus essentially on the communication process, whether through media or at
an interpersonal level. Many of the best examples of CFSC practice are created and driven at a
local level. It has been recommended that the Stop TB Partnership have a facility for tracking good
From Cough to Cure: A path of ideal behaviors in tuberculosis control
practice in all forms of communication so that it can be shared among practitioners and NTPs. This
applies particularly to highlighting examples – at the community as well as the national level – which
BARRIERS
are often poorly detected. ������ � ��������������� � ����������������� � ��������������� � ��������������� � ��������������� � ���������������
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JHU Outcome Map to strengthen DOTS � ��������������� � ���������������

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Johns Hopkins University has developed an Outcome Map to strengthen the DOTS strategy to Stop ��������������� ���������������� � ������������� � ������ � ������ � ������

�������
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TB. This is recommended as a potentially highly effective planning tool for matching communication ��������������
responses to programme needs, and for outlining key planning and measurement indicators. � ������������������ � ��������������� ���������������
������������ ���������������

The Outcome Map retrofits communication interventions on to the well-established but medically- � ��������� � ������
����������
oriented DOTS strategy for TB control. The model includes suggested activities and performance � �����������
indicators. It does not replace or complicate the DOTS strategy; rather it enhances it to include
demand generation for high-quality DOTS services and suggests strategies for encouraging

��������
treatment adherence and completion. The model introduces the idea of a “TB-free community,” ����� �������� ����� �������� ��������

�����
���������
which allows for ownership of the entire strategy at the community level by community members ���� ��������� ��������� ��������� ���������
and health-care providers. ������������������ �������������

The Cough to Cure Pathway � ������������

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Understanding patients’ behaviour is fundamental in designing interventions to strengthen �������� ������������������ �������� �������� ��������
NTPs, including communication interventions. Communication interventions need to identify key � ����������������� � ���������������� � ���������������� � ���������������� � ����������������
��������������� ��������������� �������� �������� ��������
challenges to control TB among intended populations. To assist in identifying these barriers it is ���������������� �������������
������

useful to map them out along a preferred behavioural continuum from the first sign of symptoms ���������������� � ���������������������� � ���������������������� � ����������������������
����� � ������������������� ����������������� ����������������� �����������������
(cough) to treatment completion (cure). The Academy for Educational Development has developed ���������������� ����������� ����������� �����������
� ����������������� ���������
a diagnostic and planning tool: the Cough to Cure Pathway. ��������������� � �������� � �������� � ��������
������������ � ���������������� ����������� ����������� �����������
��������� �����������������
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��������

ANNEX A
ANNEX A
 54 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 55

Annex B
Assessment of advocacy, communication
and social mobilization in national tuberculosis
programmes

Checklist
Programme funding and strategy
• What is your total budget for ACSM and the sources of funding?

Priority populations (Who?)

Budget Dates Total, $m ACSM, $m % • Who are the priority populations for ACSM activities?
NTP • How were they selected/identified?

Funding • Does the programme have specific ACSM activities for populations such as alcohol abusers,
cross-border populations, ethnic minorities, immigrants, migrant workers, injecting drug users,
National government people living in prisons, refugees, slum dwellers and the orphaned or homeless? If so, please list
the activities.
Global Fund

Other sources Behavioural goals (What?)

GAP
• Is there a national ACSM strategy/plan? Who was involved in developing it?
• What is the overall timeline and spending plan?
• How are ACSM plans and goals articulated within the national/technical plan and goals?
Implementation resources
• Who are the key stakeholders and implementers involved in ACSM activities?
• What initiatives to involve communities in TB care are implemented?
• How do communities participate in different phases/activities/in what capacity?
• How do they get involved?
• What training do the different implementers have in ACSM and TB?
• What ACSM human resources exist in the national TB programme (NTP)?
• What ACSM human capacity exists at different levels (national, state, district)?
• Are all human resource needs met? If not, what are the gaps?
Strategy design
• What type of data, for example from a KAP survey, focus group or other quantitative/qualitative
sources, is used as input to design ACSM plans?
• How are ACSM goals articulated within the overall goals of the NTP?
• What are the key behaviours identified in ACSM activities to be promoted among different popu-
lations?
• What are the key barriers to successful TB control among those populations?
• What methods are used to address people and motivate them to engage in ideal TB control
practices?
Communication activities (How)
• What activities have been planned and actually rolled-out?
• What channels/networks/institutional resources are used? What criteria were used to select
them?
• What materials have been produced?
How are ACSM activities monitored and evaluated?
• What indicators and data are used for monitoring and evaluation?
• What is the frequency of data reporting? Is it often enough (e.g. daily/weekly/monthly) to give
timely feedback on activities?
• What is the process for reporting? Who does what (who prepares reports, who are they sent to)
and how are decisions influenced by report results?
• What data can you share?
• How are different activities evaluated in terms of reach, efficacy and other indicators?
• What are the three most important ACSM needs?

ANNEX B
ANNEX B
 56 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Annex C
Examples of ACSM goals/indicators
The examples in this annex are excerpted and adapted from The Global Plan to Stop TB,
2006–20156.
Knowledge indicators
• Knowing what TB is and the difference between TB, MDR-TB and XDR-TB.
• Knowing how a person can get TB.
• Knowing what kind of people are more likely to get TB or are most susceptible to TB.
• Knowing how a person can prevent getting TB.
• Knowing if and how a person with TB can be cured.
• Knowing what a person could do to reduce his or her chances of a cure.
• Knowing the cost of TB diagnosis and treatment in the country.
• Knowing how long TB treatment lasts.
Attitude indicators
• How serious TB is considered to be as a disease. (When checking this, ask the question in
relation to other diseases or provide a scale.)
• How serious a problem TB is considered to be in the country/region.
• What a person would think if he/she were diagnosed with TB.
• What a person would do first (or how would they react) upon receiving a TB diagnosis.
• What a person thinks about the effectiveness of TB treatment.
• What a person thinks about the side effects or other problems related to TB treatment.
Health-seeking behaviour indicators
• Where people usually go if they are sick, or to treat a general health problem.
• How often people generally seek health care at a clinic or hospital.
• What a person would do if they thought they had symptoms of TB.
• What help a person would seek if they thought they had symptoms of TB.
• If a person had a cough for more than three weeks, or if they were coughing up blood in their
sputum, what they would do.
• If a person had symptoms of TB, at what point they would seek medical help.
• If a person had symptoms of TB, how long they would wait before seeking treatment.
• Who a person would talk to about TB if they were diagnosed.
Exposure to communication and mass media indicators
• Where people usually hear about TB and what sources of information can most effectively
reach people with information on TB.
• Sources from which people currently get their health information and which ones they trust
most.
ANNEX C
6 WHO, Stop TB Partnership. The Global Plan to Stop TB, 2006–2015. Geneva, World Health Organization, 2006.
ACSM for Tuberculosis Control: A Handbook for Country Programmes 57
• How often people watch television/listen to radio/read newspapers; which they listen to/watch/
read, and how often.
Stigma indicators
• The feelings people have toward others they know who have TB or have had TB.
• If a person’s close friend had TB, whether the relationship would change and how.
• In the community, how a person who has TB is regarded/treated.
• Whether HIV-positive people should be concerned about TB and why.
• Why some people are more likely to become infected with TB than others.
• Whether having TB carries the same stigma as having AIDS – or less, or more.
• If there was only one bed in a hospital for a TB patient or an AIDS patient, who should get the
bed and why.
Gender indicators
• Women usually go to a health-care facility alone.
• Men usually accompany their wives to visit a health-care facility.
• Men – or women – are considered to be more likely to get TB, or men and women have the
same risk.
• What a man in the community would do if his wife got TB.
• The reaction in a family if a family member/prospective daughter-in-law/prospective son-in-law
had TB.
Health-care worker-specific indicators
• Education on TB or HIV is provided. If yes, how often.
• The type of materials used to guide education sessions.
• The source of the materials used for TB and HIV education.
• What would help families discuss TB more openly.
• What would help people with TB discuss the disease more openly.
• What would make it easier for communities to have more open dialogue on health topics.
• The best communication channel likely to be effective in reaching people with TB in the
community.
• The communication channels that health workers should use to encourage TB or HIV
prevention practices in the community.
• The stage in their illness when people with TB usually begin seeking health care at the facility.
• How people react once they find out that they have TB.
• Who people generally tell about their illness.
• How a person who has TB is usually regarded/treated.
ANNEX C
 58 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Annex D
Planning a World TB Day event
Annex D is excerpted from Guidelines for Social Mobilization: Planning World TB Day7.
World TB Day is a valuable opportunity to raise awareness of the prevalence and impact of TB – as
well as the state of TB prevention and control efforts – at the national, regional and local levels.
Reasons for holding an event
• To highlight achievements of the NTP.
• To obtain additional political commitment.
• To mobilize new partners to address TB in their work.
• To increase the demand for TB services (diagnosis and treatment).
• To attract media attention (television, radio, newspaper) to increase understanding of TB in the
general public, and increase commitment from local leaders and politicians to support TB control
activities.
Planning steps
1) Set up a World TB Day planning committee that includes partners, organizations and other
motivated people (e.g., NGOs, student groups, religious groups, media, medical associations,
networks of people living with TB, politicians, women’s groups, HIV/AIDS organizations and
programmes). Hold regular meetings of the committee, keep minutes of the proceedings and
distribute them widely after each session.
2) Consider mobilizing external resources by involving private industry or businesses.
3) Determine interesting and relevant activities.
4) Determine what each member of the planning committee can contribute and assign tasks and
responsibilities.
5) Set deadlines for accomplishing the various tasks.
6) Make provisions to assess the impact of the event.
7) Collect information to build a case for supporting TB control.
8) Transform statistics into key messages and stories to state the extent and effects of the problem;
share success stories about what can be done to address the problem; and provide human
interest examples that document the impact of TB on the individual.
9) Design activities and events that will mobilize partners for action (forums, seminars, courses,
parades, competitions, street events and other “infotainment” events).
10) Organize media events to make news (such as a press conference with politicians or other
leaders to highlight the opening of a new DOTS centre).
ANNEX D
7 Larson H, Mahanty B. Guidelines for Social Mobilization: Planning World TB Day. Geneva, World Health Organization,
2000 (WHO/CDS/STB/2000.1).
ACSM for Tuberculosis Control: A Handbook for Country Programmes 59
11) Prepare speeches, fact sheets, video, and other visual materials with statistics and key
messages.
12) Assess the event afterwards and compile the lessons learnt.
13) Organize a “thank you” event for members of the planning committee to build on successes
and nurture partnerships for the future.
Examples of World TB Day events
The Philippine Coalition against Tuberculosis (PHILCAT) organized awareness-raising
events to promote DOTS on World TB Day. The theme was “the critical role of the private sector
in DOTS”. PHILCAT, whose members include pharmaceutical companies, announced its support
for a local foundation called the “Centre for TB in Children”. PHILCAT also sponsored a motorcade
and an entertainment event on the day. Hundreds of people participated and the media highlighted
this as an example of private sector involvement with children affected by TB. In addition, banners
with the sponsors’ names were flown on the streets and appeared on local television.
In Nigeria, a private organization in collaboration with the University Teaching Hospital organized
a national convention coinciding with World TB Day called “TB—a re-emerging infectious disease;
HIV/AIDS and the health worker”. The objective was to improve the knowledge and understanding
of the health-care staff about TB to enhance TB services and health worker–patient relations. The
event updated the staff on the importance of each element of the DOTS strategy and reinforced
their commitment to TB control.
In Jijiga, Ethiopia, children learnt the main messages about TB management and prevention by
playing the “snakes and ladders” game. Teams of five children, representing the five elements of
DOTS, took part in bicycle relay races. Participants as well as spectators had fun while learning
about the importance of everyone’s involvement in making TB control effective.
In the Philippines, the “dating game” was played on World TB Day. Four potential candidates
went out on a date with a young woman and responded to her questions from behind a screen.
The young woman chose her date for the evening, not having seen the candidate, based on his
answers. In this version of the game, one of her questions was: “How would you treat me if I had
TB?” By picking the candidate who gave the most caring response, the young woman brought
attention to the importance of a non-stigmatized attitude towards people with TB.
In Nepal, World TB Day served as the launch of “Kathmandu Valley DOTS” and the official opening
of 17 new DOTS centres. In addition, the “Dixa Daxa” award was inaugurated to honour people
who made important contributions to TB control. The event created widespread media attention
and the awards ceremony generated news about who would be honoured for their contribution to
fighting TB.
ANNEX D
 60 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 61

On World TB Day the governor of a province in Pakistan called for the start of an “adopt-a-patient”
Annex E
programme to fund treatment for people who could not otherwise afford it. The governor funded
the treatment of 10 people with TB and called on the medical community to “provide more ideas to
The stages-of-change model
improve the health situation of the population”. At the same event the importance of implementing
the DOTS strategy was highlighted, and the governor’s participation received widespread media
coverage in the province. Annex E is adapted from: Changing for Good: A Revolutionary Six-Stage Programme for
Overcoming Bad Habits and Moving Your Life Positively Forward8.
Beyond World TB Day
The list below includes other international commemorative days and events to use as a foundation The stages-of-change are:
for ACSM activities. • pre-contemplation (not yet acknowledging that there is a problem behaviour that needs to be
changed);
• contemplation (acknowledging that there is a problem but not yet ready or sure of wanting to
• 8 March: UN Day for Women’s Rights and International Peace (focus on gender,
make a change);
human rights, access to TB services).
• preparation/determination (getting ready to change);
• action/will power (changing behaviour);
• 7 April: World Health Day (DOTS is an effective treatment strategy to cure TB).
• maintenance (maintaining the behaviour change); and
• relapse (returning to former behaviour and abandoning the new changes).
• 15 May: International Day of Families (TB affects families, puts children out of school,
decreases family income).

• 31 May: World No-Tobacco Day (smoking weakens the immune system and can
further the progression from TB infection to disease).

• 11 July: World Population Day (TB impacts on life expectancy and quality of life).

• 1 October: International Day of Older Persons (TB is a disease that affects older
����������������
people; DOTS can cure TB and increase the quality of life). ������

• 17 October: International Day for the Eradication of Poverty (TB puts many families
into poverty; TB disproportionately affects those already living in poverty).

• 16 November: International Day for Tolerance (de-stigmatise people with TB).

�����������
• 20 November: Universal Children’s Day (many children are orphaned or otherwise �����������
affected by TB).

• 1 December: World AIDS Day (the dual epidemic of TB and HIV; TB is the leading
killer of people with HIV).
������������� �������
• 10 December: Human Rights Day (access to treatment and information is a human
right; discriminating against people with TB is a violation of their human rights).

�����������������

����������������������
ANNEX D

ANNEX E
8 Prochaska JO, Norcross J, DiClemente C. Changing for Good: A Revolutionary Six-Stage Programme for Overcoming Bad Habits
and Moving Your Life Positively Forward. New York, Avon Books, 1994.
 62 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Stage one: Pre-contemplation
In the pre-contemplation stage, people are not thinking seriously about changing and are not
interested in any kind of help. People in this stage tend to defend their current bad habit(s) or
dangerous situation(s) and do not feel it is a problem. They may be defensive in the face of other
people’s efforts to pressure them to take action, to go for diagnosis for example.
Stage two: Contemplation
In the contemplation stage people are more aware of the personal consequences of their negative
situation and they spend time thinking about their problem. Although they are able to consider the
possibility of changing, they tend to be ambivalent about it.
In this stage, people weigh the benefits and the negative aspects of modifying their behaviour.
Although they think about the negatives of their bad habit or situation and the positives associated
with doing something about it, they may doubt that the long-term benefits associated with taking
action will outweigh the short-term costs.
It might take as little as a few weeks or as long as a lifetime to get through the contemplation stage.
(In fact, some people think and think and think about giving up their bad habit or changing their
situation, and may die never having moved beyond this stage). On the positive side, people are
more open to receiving information about their bad habit or dangerous situation, and more likely to
actually use educational interventions and reflect on their own feelings and thoughts concerning
their bad habit or situation.
Stage three: Preparation/determination
In the preparation/determination stage, people have made a commitment to make a change.
Their motivation for changing is reflected by statements such as: “I’ve got to do something about
this– this is serious. Something has to change. What can I do?” During this phase people are
taking small steps toward changing their situation. They are trying to gather information about what
they will need to do to change their behaviour.
For example, they may talk to a health-care provider or a friend, trying to find out what resources
are available to help them. Too often, people skip this stage; they try to move directly from
contemplation to action and fail because they have not adequately researched or accepted what
it is going to take to make a behaviour change.
Stage four: Action/will power
This is the stage where people believe they have the ability to change and are actively involved in
taking steps to change their bad behaviour or dangerous situation by using a variety of different
techniques.
This is the shortest of all the stages. The amount of time people spend in action varies. It generally
lasts about six months, but it can be as short as one hour! This is a stage when people depend
most on their own will power. They are making overt efforts to change their behaviour and are at
greatest risk of moving back to their previous, negative behaviour or situation.
ANNEX E
ACSM for Tuberculosis Control: A Handbook for Country Programmes 63
Mentally, they review their commitment to themselves and develop plans to deal with both personal
and external pressures that may lead to slipping back to their former situation. They may use short-
term rewards to sustain their motivation, and analyse their behaviour change efforts in a way that
enhances their self-confidence. People in this stage also tend to be open to receiving help and are
also likely to seek support from others (a very important element).
Stage five: Maintenance
Maintenance involves being able to successfully avoid any temptations to return to the bad habit or
dangerous situation. The goal of the maintenance stage is to maintain the new status quo. People
in this stage tend to remind themselves of how much progress they have made.
People in maintenance constantly reformulate the rules of their lives and are acquiring new skills to
deal with life and avoid returning to their previous behaviour or situation. They are able to anticipate
the situations in which this could occur and prepare coping strategies in advance. They remain
aware that what they are striving for is personally important. They are patient with themselves and
recognize that it often takes a while to change old behaviour patterns and practice new ones until
they become “normal” to them. Even though they may have thoughts of returning to their old habits
or situations, they resist the temptation.
Stage six: Relapse
Along the way to the stable reduction of a bad habit or removal from a dangerous situation, most
people experience relapse, a return to the previous behaviour or situation. In fact, it is much more
common to have at least one relapse than not. Relapse is often accompanied by feelings of
discouragement and seeing oneself as a failure.
While a relapse can be discouraging, the majority of people who successfully change do not follow
a straight path to a lifetime free of negative behaviour or situations. Rather, they cycle through the
five stages several times before achieving a stable behaviour change. Consequently, the stages-
of-change model considers relapse to be normal.
ANNEX E
 64 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 65

Annex F
Worksheet for a creative/strategic brief

Annex F has been excerpted and adapted from Making Health Communication Programmes
Work9. Support statement/the reason
Include the reasons the key promise/benefit
outweighs the obstacles and the reasons that what
you are promising or promoting is beneficial. These
Intended audiences often become the messages.
What types of people do you
want to reach?

Tone
What feeling or personality should your message
have? Should it be authoritative, light, emotional?
Objectives Choose a tone.
What do you want your
intended audiences to do
after they hear, watch, or
experience the message?
Media
What channels will the message use, or what
form will the message take? Television? Radio?
Newspaper? Internet? Poster? Flyer? All of the
Obstacles above?
What beliefs, cultural
practices, peer pressure,
misinformation, etc. stand
between your audience
and the desired objective? Openings
What opportunities (times and places) exist for
Key promise reaching your audience?
Select one single promise/
benefit that the audience
will experience upon seeing,
hearing, or reading the
objectives that you have set.
Creative considerations
Is there anything else the creative staff should know?
Will it be in more than one language? Should they
make sure that all nationalities are represented?

Note: All briefs should be accompanied by a page summarizing the background situation of the work/activity.

ANNEX F
ANNEX F

9 U.S. Department of Health and Human Services, National Cancer Institute. Making Health Communication Programmes Work,
Bethesda, MD, 2001.
 66 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 67

SCREENING QUESTIONNAIRE

Annex G Project Name

Sample recruitment document for a focus-group Respondent’s name

discussion Address

Annex G is adapted from an internal recruitment screener, developed in 2006 and used by
Occupation Telephone
the Academy for Educational Development in Viet Nam to recruit individuals among heads of
households to participate in a focus group on information-gathering and media habits, and to
pre-test television spots. Interview date Started at Ended at Length

Office use only Observed by Quality Validated

control by by

Location Group no. Gender

Quota
Name 1 Rural commune 1 Male 1

District town 2

Name 2 Rural commune 3 Female 2

District town 4

Name 3 Rural commune 5

District town 6

Name 4 Rural commune 7

District town 8

Interviewer I.D.

I declare that the respondent, whose name and address appear above, was unknown to me until the interview. I confirm
that, before returning this questionnaire, I have checked that it complies with – and was carried out in accordance with – the
instructions supplied to me for this study. I understand that the information given to me during the interview must be kept
confidential.

ANNEX G
ANNEX G

Signed Date
 68 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 69

Hello, I am ……… [insert interviewer name], an interviewer from [insert organization name]. We are currently having discussions with 6. Now I am going to read out some statements. Please let me know if you agree with any of them.
people who live in this area on their lives. Could I speak to the head of the household please?
Agree Disagree
a) I like watching television commercials. 1 2
Speak to contact person
b) I love watching television and do not mind television commercials interrupting
1. Do you or any member in your household, relatives or close friends work for any of the following businesses? my programme. 1 2
c) I like watching television but would prefer to not have television commercials interrupting
my programme. 1 2
Public relations, media (television station, radio, newspaper) 1 TERMINATE
d) I immediately switch to another channel any time I see an advertising break. 1 2
Advertising 2 TERMINATE
Marketing/market research/new-product development 3 TERMINATE
--> TERMINATE IF RESPONDENT CHOSE CODE 1 FOR STATEMENT D.
None of the above 6 CONTINUE

7. Could you please let us know whether you agree or disagree with the following statement.
2. In the past six months, have you, yourself, ever participated in any market survey or group discussions?
READ OUT EACH STATEMENT AND RECORD THE ANSWERS BELOW.

Yes 1 TERMINATE
Agree Disagree
No 2 CONTINUE
I do not have trouble expressing my opinion. 1 2
Getting together, talking to others is a good way to know more. 1 2
3. Could you please tell us your year of birth? [Record year of birth and assign a code based on age.]
I like sharing my opinions with others. 1 2

Under 20 years old 1 TERMINATE

21–29 years old
30–39 years old
Over 39 years old
4. Which of the following best describes your marital status?
Single
Married with child/children
Married without children
Refused
2 CONTINUE
CONTINUE ONLY IF THE RESPONDENT AGREES TO EACH OF THE THREE STATEMENTS ABOVE.
3 CONTINUE
THEN READ ALOUD:
4 CONTINUE
We
estimated to last about two hours. Whatever information you provide will be kept confidential and will not be shared with anyone else.
You will not receive any payment for participating but your answers may help to improve health in your community. You do not have to
answer any questions that you do not want to answer. Would you like to participate?
1 TERMINATE
2 CONTINUE
Agree to participate 1 INVITE
3 TERMINATE
Refuse to participate 2 Thank and terminate
4 TERMINATE

5. How often do you watch television?

Three or more times a week 1 CONTINUE

Two or fewer times a week 2 TERMINATE

ANNEX G
ANNEX G
 70 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 71

Annex H
Sample guide for a focus-group discussion Ask the following questions.

This sample guide was prepared by PATH in 2004 for people living with HIV in Ukraine to talk
about their knowledge of TB and their experiences with it.
The instructions in italics address the facilitator.
What do you think about the situation of health care in Ukraine right now?
Tell me about your experiences when you have gone to a medical facility to seek health care.
Probe:
• Where do you go for health care? Who provides health care to you?

Date (day/month/year) • How long do you wait to be seen by a trained medical provider?

Time focus-group discussion began • What is the medical provider’s attitude to you? What do they say and do? What are your feelings about this?

Name of facilitator • In general, what do you like when you go to see a medical provider?
Time focus-group discussion ended
• In general, what do you dislike when you go to see a medical provider?
Name of recorder
• Describe a particular experience you had when you sought health-care at a medical facility.
Age of group participants: __ >30 __<30

Health-seeking practices
Introduction • Do you usually get medical care when you feel a need of it?
Read the introduction; it explains the purpose of the group.
Probe:
Ask participants to complete the background information form. This should be done individually.
• If not, why not? (Do not read this list – just take notes of responses or give an example if necessary.)
Possible reasons include:
Tell participants that if they participate in the focus-group discussion, they will be asked not to
- cost
repeat any information discussed in the group. While the study staff expect all participants to follow
- transportation
this instruction, they cannot guarantee that what a participant says in the group will not be repeated
- not sure where to go
outside the group by one of the other participants.
- stigma
- privacy and confidentiality issues
Anyone who participates in a focus-group discussion is free to use a name other than their own
- do not like to wait
during the discussion.
- have to care for children
- attitude of health providers
Tell participants that, if at any time they do not feel comfortable with a topic, they are not required
- cannot leave work
to speak and they are completely free to end their participation in the meeting at any time. There
- afraid to find out that something is really wrong
are no wrong or right answers.
- will probably be told that nothing is wrong
- other
Attitudes towards health services
Begin the discussion by saying: • How often in a year do you get medical care?

Today we will be discussing health care, how we seek and receive health care, and how Probe:
we learn information about health topics. These issues are important to men and women in
Donetsk, Kyiv and across Ukraine. We will talk about TB in particular.
Let us first talk about your experiences when you have needed medical care.
Probe:
Ask each participant to answer in turn. Follow up with questions then open up the discussion to the
group. Explore feelings about where participants go for medical care, and their reasons for seeking
medical care. Discuss how people feel about seeking health care and how they are treated when
they go to medical facilities.
- For what types of medical problems?
- Where do you go for medical care?
- How long do you normally wait before you go get medical care?
- When you realize something is wrong, what symptoms tell you this?
- What else? What other signs tell you when your health needs attention?
- Take coughing, for example, when do you know that the cough is not normal?

ANNEX H
ANNEX H
 72 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 73

Knowledge of TB Probe:
• Have you ever heard of TB? • If from the media, what source? (Do not read the list; take note of responses.)
- television
Probe: - radio
- What have you heard about TB? - billboards
- How did you first hear of TB? - magazines
- What are the symptoms or signs of TB? - newspapers
- brochures or other printed matter
• In your opinion, how is TB transmitted (passed from one person to another)? - other.
Probe: • What source of information do you trust the most and why?
- In what ways are you sure that TB cannot be transmitted? • From what source would you like to learn more about TB?
- How is TB treated? What can happen if it is not treated?
- Can TB be cured? Probe:
- In your opinion, is TB a major health problem in Ukraine? - If media, what kind of media?
- Who is at particular risk of getting TB? - If people, what people?
- If printed materials, what kind? (Describe.)
- Why do you prefer this source of information? What makes this source trustworthy?
Attitudes toward people with TB
• If you were to read a brochure or poster about TB, what would make it interesting to you?
• Have you ever know someone who has TB?
- colourful
- celebrity/famous person
Probe:
- simple, easy-to-read
- How did you learn they had TB?
- good content and information
- What was your reaction? What did you think/feel at that time?
- other.
- Did anything change in the way you relate to that person?
• If you were to see a television spot informing you about TB, what would make it interesting to you?
• How would you feel if a member of your family had TB?
Probe:
- What should a good television spot on TB be like?
Probe:
- What style should it be?
- How would you treat them? What would you do for them?
- How long should it take?
- Would anything change in the way you relate to them? If yes, what?
- What information should it include?
- Would you give your family member any advice? If so, what advice would
- At what time of day should this television spot be shown?
you give them?
- What do you feel about the TB medical facilities?
• How about the radio – what would make a radio spot interesting to listen to?
Probe:
Probe:
- What should a good radio spot on TB be like?
- Would you feel comfortable visiting such facilities in case of TB symptoms?
- What style should it be?
- Do you think you would get appropriate care, diagnosis and treatment?
- How long should it take?
- Do you fear that you will get infected?
- What information should it include?
- Do you feel stigmatized?
- At what time of day should this radio spot be broadcast?
- Are you sure that confidentiality would be assured in these facilities?
• If you saw a spot about TB on television, or heard one on the radio, what would make you act or take the
Opinions & preferences regarding effective media information seriously?
• Where do you get information about health topics?
• What messages about TB are most important to pass to the public?
Probe:
• If from a person, from whom? (Do not read the list; take note of responses.)
- friends or co-workers
- family members or spouse
- medical provider

ANNEX H
ANNEX H

- school teacher
- other.
 74 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Conclusion
We will close today’s meeting with some final thoughts.
Read the following text to the participant(s).
Some of the topics we have discussed are very personal for people to talk about. We want
to thank you for sharing your honest thoughts and personal opinions today. Think for a
moment about what we have talked about.
Ask each person if there is anything else she/he would like to add. Conclude by saying:
We are now finished. How do you feel about our discussion? Do you have any suggestions
for improving the group process?
Here are our business cards. If you have any more questions or comments you wish to
share after the interview, do not hesitate to contact us. We have refreshments – coffee and
cookies – here for you.
Thank the participants and tell them that their contribution has been very valuable. Emphasize that
this information will be used to improve health education campaigns according to their realities and
preferences.
After the focus group
Immediately after the discussion, note-taker and/or facilitator:
• debrief together;
• look over the forms with the participants’ background information;
• make a note of suggested changes in the way the group or interview should be conducted or in
the technical aspects of the logistics;
• revise, edit and complete notes.
DO NOT DELAY THE FOLLOWING STEPS
That afternoon or evening, note-taker and/or facilitator:
• review the recording; make clarification notes as necessary;
• complete and correct the notes in accordance with the recording;
• summarize important themes or points made in the summary section of the interview;
• send the tape and the clarification notes to be transcribed;
• meet with the other project staff to discuss how the focus groups and interviews are going;
• share suggestions for changes to the guide, the interviews or the focus-group discussions.
ANNEX H
ACSM for Tuberculosis Control: A Handbook for Country Programmes 75
Annex I
Sample questions for pre-testing materials
Annex I is adapted from Developing Health and Family Planning Print Materials for Low-Literate Audi-
ences: A Guide.10
Sample questions for pre-testing printed materials
Ask these questions about each page of the material being tested:
1) What information is this page trying to convey?
2) In your own words, what does the text mean?
3) What does the illustration show?
4) Do the words match the picture on the page? Why, or why not?
5) Are there any words in the text you do not understand? Which ones? (If any, explain the meaning to
respondents and ask them to suggest other words that can be used to convey that meaning.)
6) Are there any words that you think others might have trouble reading or understanding? (Again, ask
for alternatives.)
7) Are there sentences or ideas that are not clear? (If so, have respondents show you what they are.
After explaining the intended message, ask the group to discuss better ways to convey it.)
8) Is there anything on this page that you like? What?
9) Is there anything on this page that you do not like? What?
10) Is there anything on this page that is confusing? What?
11) Is there anything about the pictures or the writing that might offend or embarrass some people?
What? (Ask for alternatives.)
Ask these questions about the entire material:
12) Do you think the material is asking you to do anything in particular? What?
13) What do you think this material is saying overall?
14) Do you think the material is meant for people like yourself? Why?
15) What can be done to make this material better?
Ask the above questions for each version of the material, and then ask:
16) Which version of the material do you prefer? Why?
ANNEX I
10 PATH. Developing Health and Family Planning Print Materials for Low-Literate Audiences: A Guide. Seattle, 1996.
 76 ACSM for Tuberculosis Control: A Handbook for Country Programmes
Sample questions for pre-testing radio and video
The following sample questions have been excerpted and adapted from How to Conduct
Effective Pre-tests.11
1) In your own words, what do you think is the message of this programme?
2) Are there any words in the programme whose meanings you did not understand? If yes,
identify the word(s) then ask: What do you think [mention the word] might mean? Which word do
you think should be used instead?
3) Can you hear and understand what they are saying in the programme? If not, what can you
not hear or understand?
4) Are there any scenes in the programme that you did not understand? If yes, explain.
5) Are the music, sound effects, visuals and dialogue appropriate for this programme?
6) Is there anything in the programme that you think is not true? If yes, what? What about it
seems untrue?
7) Does the programme say anything that might offend anyone in your community? What?
8) What did you like most about the programme?
9) Is there anything about the programme that you do not like? If yes, what? How would you say
it so that you would like it?
10) What do you think this programme is asking you to do?
11) Are you willing to follow the advice given to you? What would cause you to be willing to follow
the advice? What would discourage you?
12) To whom do you think this programme is directed? What about it makes you think that?
13) Who are the people in the programme? What are they doing?
14) Where do you think they are?
15) What do you think you will remember most about this programme?
16) Do the people in the programme talk the way people from here talk? Do they look like people
from here? If not, what would you change?
17) In your opinion, what could be done to improve this programme?
Two or more versions being pre-tested
If you have multiple versions of your spot or programme, ask the above questions for each
version, and then ask the following comparison questions:
1) Which of the two programmes do you like best? Why?
2) If you had to prepare a programme containing the best parts of each version, which parts
would you choose from each?
ANNEX I
11 Family Health International. How to Conduct Effective Pre-tests. Research Triangle Park, NC.
ACSM for Tuberculosis Control: A Handbook for Country Programmes 77
Annex J
Sample questions for evaluating an advocacy initiative
Adapted from Advocacy Tools and Guidelines: Promoting Policy Change. Atlanta, GA, CARE, 2001.
Evaluating impact
• Have policy changes resulted in improvements in TB treatment or access to treatment? Why/why
not? Can data be provided to support these findings?
• Have policy changes contributed to protecting, promoting or expanding people’s rights and mitigating
discrimination based on stigma?
Evaluating effects
• Has the intended policy change occurred or are the prospects better than they were before?
• Have new policies been approved or have outdated/adverse polices been changed? Are policies
enacted at the national, regional and/or local levels? Why/why not?
• What factors enabled/hindered the success of the policy change (in other words, the creation,
revision or enactment of policies)?
• Were bills or proposals formally introduced in the legislature or other government body or were
informal decisions made?
• Who made final decisions that enabled/hindered the policy change?
Evaluating the strategy
• Were the appropriate primary and secondary populations selected? Did the targets of advocacy have
to be changed along the way? Why/why not?
• Did the advocacy messages change opinions or knowledge on the policy issue? Which messages
were most successful and which failed to convey the main point(s)?
• Were appropriate roles chosen for the advocacy initiative? Could other roles have been more
effective?
• Was advocacy conducted within a larger partnership or coalition? What were the benefits/drawbacks
of the arrangement?
• Has the advocacy initiative increased the ability of community groups and/or local organizations to
represent their own interests?
• Did the advocacy initiative raise public awareness and interest in the policy issue?
• What were the major obstacles faced by the advocacy initiative? What was done to overcome those
obstacles?
• What can be learnt from the strategy implementation for future advocacy initiatives?
ANNEX J
 78 ACSM for Tuberculosis Control: A Handbook for Country Programmes ACSM for Tuberculosis Control: A Handbook for Country Programmes 79

Annex K
The Patients’ Charter for Tuberculosis Care 2. Dignity
a) The right to be treated with respect and dignity, including the delivery of services without
stigma, prejudice or discrimination by health-care providers and authorities.

The Patients’ Charter for Tuberculosis Care (the Charter)12 outlines the rights and responsibilities of b) The right to high-quality health care in a dignified environment, with moral support from family,
people with tuberculosis (TB). It empowers people with the disease and their communities through friends and the community.
knowledge of the disease. Initiated and developed by patients from around the world, the Charter
makes the relationship with health-care providers a mutually beneficial one.
3. Information
a) The right to information about the availability of health-care services for TB, and the responsibilities,
The Charter sets out the ways in which patients, communities, health-care providers – both private
engagements and direct or indirect costs involved.
and public – and governments can work together as partners in a positive and open relationship to
improve standards of TB care and enhance the effectiveness of the health-care process. It allows
b) The right to receive a timely, concise and clear description of the medical condition, with
all parties to be held more accountable to each other, fostering mutual interaction and a “positive
diagnosis, prognosis (an opinion as to the likely future course of the illness) and treatment
partnership”.
proposed, with communication of common risks and appropriate alternatives.
Developed in tandem with the International Standards for Tuberculosis Care13 to promote a “patient-
c) The right to know the names and dosages of any medication or intervention to be prescribed,
centred” approach, the Charter adheres to the principles on health and human rights of the United
its normal actions and potential side-effects and its possible impact on other conditions or
Nations, UNESCO, WHO and the Council of Europe, as well as other local and national charters
treatments.
and conventions.14
d) The right of access to medical information relating to the patient’s condition and treatment
The Charter embodies the principle of greater involvement of people with TB (GIPT). This affirms
and to a copy of the medical records if requested by the patient or a person authorized by the
that the empowerment of people with the disease is the catalyst for effective collaboration with
patient.
health-care providers and authorities and is essential to victory in the fight to stop TB. The Charter,
the first global “patient-powered” standard for care, is a cooperative tool, forged from a common
e) The right to meet, share experiences with peers and other patients and to voluntary counselling
cause, for the entire TB community.
at any time, from diagnosis to completion of treatment.
Patients’ rights
4. Choice
1. Care a) The right to a second medical opinion, with access to past medical records.
a) The right to free and equitable access to TB care, from diagnosis to completion of treatment,
regardless of resources, race, gender, age, language, legal status, religious beliefs, sexual
b) The right to accept or refuse surgical interventions if chemotherapy is possible and to be
orientation, culture or health status.
informed of the likely medical and statutory consequences within the context of a communicable
disease.
b) The right to receive medical advice and treatment that fully meets the new International Standards
for Tuberculosis Care, centring on patient needs, including the needs of patients with MDR-TB or
c) The right to choose whether or not to take part in research programmes without compromising
TB-HIV co-infection, and preventive treatment for young children and others considered to be at
care.
high risk.

c) The right to benefit from proactive health sector community outreach, education and prevention 5. Confidence
campaigns as part of comprehensive health-care programmes. a) The right to respect for personal privacy, dignity, religious beliefs and culture.

b) The right to confidentiality relating to the medical condition, with information released to other
authorities contingent upon the patient’s consent.

12 Patients; Charter for Tuberculosis Care; Patients’ Rights and Responsibilities. World Care Council, 2006 6. Justice
(http://www.worldcarecouncil.org/pdf/). a) The right to make a complaint through channels provided for this purpose by the health authority
13 International Standards for Tuberculosis Care: http://www.worldcarecouncil.org
and to have any complaint dealt with promptly and fairly.
14 United Nations CESCR General Comment 14 on the right to health: http://www.worldcarecouncil.org/pdf/
b) The right to appeal to a higher authority if the above is not respected and to be informed in
WHO Ottawa Charter on health promotion: http://www.worldcarecouncil.org/pdf/ writing of the outcome.

ANNEX K
ANNEX K

The Council of Europe Convention for the Protection of Human Rights and Dignity/ biology and medicine: http://www.
worldcarecouncil.org/pdf/

UNESCO Universal Draft Declaration on Bioethics and Human Rights: http://www.worldcarecouncil.org/pdf/

 80 ACSM for Tuberculosis Control: A Handbook for Country Programmes

7. Organization
a) The right to join, or to establish, organizations of people with or affected by TB, and to seek
support for the development of these clubs and community-based associations through health-
care providers, authorities and civil society.

b) The right to participate as “stakeholders” in the development, implementation, monitoring and

evaluation of TB policies and programmes with local, national and international health authorities.

8. Security
a) The right to job security after diagnosis or appropriate rehabilitation upon completion of
treatment.

b) The right to nutritional security or food supplements if needed to meet treatment requirements.

Patients’ responsibilities

1. Share information
a) The responsibility to provide as much information as possible to health-care providers about
present health, past illnesses, any allergies and any other relevant details.

b) The responsibility to provide information to health-care providers about contacts with immediate
family, friends and others who may be vulnerable to TB or who may have been infected.

2. Follow treatment
a) The responsibility to follow the prescribed and agreed treatment regimen and to conscientiously
comply with the instructions given to protect the patient’s health and that of others.

b) The responsibility to inform health-care providers of any difficulties or problems in following

treatment, or if any part of the treatment is not clearly understood.

3. Contribute to community health

a) The responsibility to contribute to community well-being by encouraging others to seek medical
advice if they exhibit symptoms of TB.

b) The responsibility to show consideration for the rights of other patients and health-care providers,
understanding that this is the dignified basis and respectful foundation of the TB community.

4. Solidarity
a) The moral responsibility to show solidarity with other patients, marching together towards cure.

b) The moral responsibility to share information and knowledge gained during treatment and to
share this expertise with others in the community, making empowerment contagious.

c) The moral responsibility to join in efforts to make the community free of TB.
Help turn these words into realities. Support the drive towards implementation in the community.
Sign online at http://www.wcc-tb.org or sign-up by SMS text at +33 679 486 024.

In common cause, with mutual respect, together we can raise the standards of

ANNEX K
TB care.
ANNEX K
 ISBN 978 92 4 159618 3

www.stoptb.org